A client arrives to the emergency department complaining of acute onset of nausea with projectile vomiting. The nurse's assessment findings include high-pitched sounds in the left upper quadrant. Which gastrointestinal disorder is consistent with these findings?

Colorectal cancer

Paralytic ileus

Large bowel obstruction

Small bowel obstruction

Answer and Explanation

The Correct Answer is D

Choice A Reason: Colorectal cancer is not likely to cause nausea with projectile vomiting or high-pitched sounds in the left upper quadrant. Colorectal cancer may cause symptoms such as rectal bleeding, change in bowel habits, abdominal pain, or weight loss.

Choice B Reason: Paralytic ileus is a condition where the bowel stops working and does not contract or move food along. Paralytic ileus may cause symptoms such as abdominal distension, absence of bowel sounds, constipation, or vomiting.

Choice C Reason: Large bowel obstruction is a blockage of the colon or rectum that prevents the passage of stool. Large bowel obstruction may cause symptoms such as abdominal distension, low-pitched sounds in the right lower quadrant, constipation, or ribbon-like stools.

Choice D Reason: Small bowel obstruction is a blockage of the small intestine that prevents the passage of food and fluids. Small bowel obstruction may cause symptoms such as nausea with projectile vomiting, high-pitched sounds in the left upper quadrant, abdominal cramps, or dehydration.

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Correct Answer is D

Explanation

Choice A Reason: This is incorrect because administering medications and electrolytes is not the primary purpose of inserting a nasogastric tube for a client with acute peritonitis. Medications and electrolytes can be given through other routes, such as IV or oral.

Choice B Reason: This is incorrect because dilating the stomach as a presurgical preparation is not a relevant Reason for inserting a nasogastric tube for a client with acute peritonitis. Dilating the stomach may be done before some types of gastric surgery, but it does not apply to peritonitis.

Choice C Reason: This is incorrect because stating that you will not be able to eat for several days is not an adequate explanation for inserting a nasogastric tube for a client with acute peritonitis. This statement does not address the rationale or the benefits of the procedure. It may also cause anxiety and resentment in the client.

Choice D Reason: This is the correct choice because removing secretions and decompressing the stomach is the main Reason for inserting a nasogastric tube for a client with acute peritonitis. Peritonitis is an inflammation of the peritoneum, the membrane that lines the abdominal cavity. It can cause abdominal distension, pain, nausea, and vomiting. A nasogastric tube can suction out the gastric contents and reduce the pressure and irritation in the abdomen.

A. Obtain the client's blood glucose every 12 hr. B. Change the IV site dressing every 4 days. C. Change the IV tubing every 24 hr. D. Weigh the client every other day.

Correct Answer is C

Explanation

Choice A Reason: Obtaining the client's blood glucose every 12 hr is not enough, as the nurse should monitor it more frequently, at least every 4 to 6 hr, to prevent hyperglycemia or hypoglycemia. TPN is a high-glucose solution that can affect the blood sugar levels.

Choice B Reason: Changing the IV site dressing every 4 days is not enough, as the nurse should change it daily or as needed to prevent infection. TPN is a high-risk solution that can introduce microorganisms into the bloodstream.

Choice C Reason: This is the correct choice. Changing the IV tubing every 24 hr is recommended to prevent infection and maintain sterility. TPN is a complex solution that can support bacterial growth and contamination.

Choice D Reason: Weighing the client every other day is not enough, as the nurse should weigh the client daily to evaluate fluid balance and nutritional status. TPN can cause fluid retention or depletion, as well as weight gain or loss.

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A client arrives to the emergency department complaining of acute onset of nausea with projectile vomiting. The nurse's assessment findings include high-pitched sounds in the left upper quadrant. Which gastrointestinal disorder is consistent with these findings?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse caring for a client with acute peritonitis reviews the physician's orders. The orders include an NPO diet, insertion of a nasogastric tube set to low intermittent suction, and IV fluids at 50 mL per hour. When asked why he will need the NG tube, what is the nurse's best reply?

Correct Answer is D

Explanation

A nurse is assessing a client who is receiving total parenteral nutrition (TPN) therapy via an infusion pump. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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