A nurse is caring for a patient who came to the emergency department with abdominal distention and is now on the medical-surgical unit with an NG tube in place to low gastric suction.
The patient reports anxiety, discomfort, and a feeling of bloating.

Which of the following actions is the nurse's priority?

Choice A rationale

Percussing the abdomen is a part of a comprehensive assessment but is not the immediate priority in this acute situation. A sudden onset of sharp pain with a rigid abdomen suggests a potential perforation, which is a life-threatening emergency. The priority is to act on this clinical suspicion to prevent rapid deterioration.

Choice B rationale

Taking vital signs is an important nursing action, but in a suspected perforation, it is not the first priority. While vital signs will likely show signs of shock (e.g., hypotension, tachycardia), the most critical action is to alert the healthcare provider so definitive intervention can be initiated without delay.

Choice C rationale

A sudden onset of sharp abdominal pain combined with a tense, rigid abdomen suggests a ruptured peptic ulcer, which is a medical emergency due to the release of gastric or duodenal contents into the peritoneal cavity. This can lead to peritonitis and sepsis, requiring immediate surgical intervention.

Choice D rationale

Administering pain medication without a definitive diagnosis and plan of care could mask critical symptoms and delay necessary surgical intervention. While managing pain is important, it is secondary to addressing the underlying life-threatening emergency of a potential perforation.

Choice A rationale

High-dose corticosteroid therapy, such as with prednisone, can cause hypokalemia by increasing potassium excretion in the kidneys. These steroids mimic the action of aldosterone, which promotes sodium reabsorption and potassium excretion in the distal convoluted tubules and collecting ducts. This process leads to increased urinary loss of potassium, potentially causing a serum potassium level below the normal range of 3.5 to 5.0 mEq/L.

Choice B rationale

Hypermagnesemia is not a typical side effect of corticosteroid therapy. Corticosteroids primarily affect sodium and potassium balance. Hypermagnesemia is more commonly associated with kidney failure or excessive intake of magnesium-containing medications. The kidneys are highly efficient at excreting magnesium, so elevated levels (normal range 1.5 to 2.5 mEq/L) are rare unless renal function is compromised.

Choice C rationale

Corticosteroid therapy actually increases the excretion of potassium from the body, leading to a decrease in serum potassium levels, not an increase. The mineralocorticoid effects of these drugs cause increased activity of the sodium-potassium pump in renal tubules, leading to the exchange of potassium for sodium, resulting in increased urinary potassium loss and a risk for hypokalemia.

Choice D rationale

While some electrolyte imbalances can occur, hypomagnesemia is not a primary concern directly linked to high-dose corticosteroid therapy. Corticosteroids' main effect on electrolytes is their mineralocorticoid activity, which primarily targets sodium and potassium regulation. Hypomagnesemia is more commonly associated with conditions like chronic alcoholism, malnutrition, or gastrointestinal losses.