A client presents to the emergency department vomiting dark brown emesis and in severe abdominal pain. The client reports to the nurse of recently being diagnosed with adenocarcinoma of the small intestine. After auscultating bowel sounds and obtaining vital signs, which prescription should the nurse implement next?
Insert a nasogastric tube (NGT) and attach to low intermittent suction.
Place an indwelling urinary catheter and attach a bedside drainage unit.
Send the client to x-ray for a flat plate of the abdomen.
Give a prescribed analgesic for temperature above 101°F (38.3°C).
The Correct Answer is A
A. Inserting a nasogastric tube (NGT) and attaching it to low intermittent suction would be appropriate in this situation. Dark brown emesis could indicate gastrointestinal bleeding, which may require gastric decompression to prevent further vomiting and assess the volume and characteristics of the gastric contents.
B. Placing an indwelling urinary catheter and attaching a bedside drainage unit is not the priority intervention in this scenario.
C. Sending the client to x-ray for a flat plate of the abdomen may provide diagnostic information, but it is not the most immediate intervention needed in this situation.
D. Giving a prescribed analgesic for a temperature above 101°F (38.3°C) is not the priority intervention in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Obstruction of bile flow leads to accumulation of bilirubin, a pigment produced by the breakdown of red blood cells, in the bloodstream and causes jaundice (yellowing of the sclera). Yellow sclera is a concerning sign that should be reported promptly to the healthcare provider as it indicates potential bile duct obstruction and impaired liver function
A. Amber urine refers to urine that is dark yellow, often indicating concentrated urine due to dehydration or certain medications. While amber urine may be noted in various conditions, it is not specifically indicative of a complication related to cholelithiasis.
C. While flatulence may be uncomfortable for the client, it is not typically indicative of a complication such as a gallstone lodged in the common bile duct.
D. belching may be uncomfortable for the client but is not typically indicative of a complication such as a gallstone lodged in the common bile duct.
Correct Answer is A
Explanation
A. Consuming dairy products, especially those rich in milk and cream, can stimulate gastric acid secretion and exacerbate symptoms of a duodenal ulcer. Therefore, it is essential for the nurse to review with the client the importance of avoiding foods that can aggravate the ulcer and worsen symptoms.
B. While reinforcing teaching about dietary modifications is important, encouraging the client to make a list of snack foods high in dairy content would not address the issue of avoiding dairy products to protect the duodenal ulcer.
C. While switching to decaffeinated coffee and tea can be beneficial for individuals with duodenal ulcers, it does not directly address the client's misconception about using dairy products to coat and protect the ulcer.
D. Eating frequent small meals can help reduce discomfort associated with duodenal ulcers by minimizing gastric acid secretion and preventing large fluctuations in stomach volume.
However, this option does not address the client's misconception.
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