A nurse is caring for a client diagnosed with peptic ulcer disease. The nurse should monitor the client for which of the following findings as an indication of gastrointestinal perforation?
Bradycardia
Hyperactive bowel sounds
Increased blood pressure
Sudden abdominal pain
The Correct Answer is D
A. Bradycardia is not typically associated with gastrointestinal perforation. Instead, tachycardia may be observed due to the body's response to a potential emergency or shock.
B. Hyperactive bowel sounds are not typically associated with gastrointestinal perforation. In fact, bowel sounds may decrease or become absent in severe cases of peritonitis or abdominal emergencies.
C. Increased blood pressure is not typically associated with gastrointestinal perforation. Hypotension may be observed due to hypovolemia resulting from fluid leakage into the peritoneal cavity.
D. Sudden abdominal pain is a key clinical manifestation of gastrointestinal perforation. The perforation of the stomach or intestines allows the contents to leak into the abdominal cavity, leading to peritonitis. Sudden and severe abdominal pain is a hallmark symptom, often described as sharp, stabbing, and constant.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Positioning the client on the right side is not a standard recommendation for gastric lavage. The standard position is typically on the left side to facilitate the drainage of gastric contents.
B. Instilling 1000 mL of sterile saline is not a recommended action for gastric lavage. Gastric lavage involves the removal of stomach contents rather than instilling fluids.
C. Withdrawing fluid until it is clear is the correct action. Gastric lavage is a medical procedure used to empty the stomach contents. The process involves introducing small amounts of fluid (such as saline) into the stomach and then aspirating it back, along with gastric contents, until the aspirate is clear.
D. Connecting the NG tube to high continuous suction is not a standard approach for gastric lavage. Gastric lavage involves intermittent instillation and withdrawal of small amounts of fluid to clear the stomach.
Correct Answer is A
Explanation
A. Regular insulin:
Regular insulin, also known as short-acting insulin, is commonly used in the initial management of diabetic ketoacidosis. It has a relatively rapid onset of action, making it suitable for addressing the acute and severe nature of DKA.
B. Insulin detemir:
Insulin detemir is a long-acting insulin analog. It is not the preferred choice for addressing the acute insulin needs in DKA; instead, it is used for basal insulin requirements in the maintenance phase of diabetes management.
C. Insulin glargine:
Insulin glargine is a long-acting insulin analog used for basal insulin coverage. Like insulin detemir, it is not the first choice for addressing the acute insulin needs in the initial treatment of DKA.
D. NPH insulin:
NPH (Neutral Protamine Hagedorn) insulin is an intermediate-acting insulin. While it has a role in diabetes management, it is not the preferred choice for the initial treatment of DKA. NPH insulin has a slower onset and longer duration compared to regular insulin.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today