A nurse is measuring a client's oral temperature. The client informs the nurse that he has just eaten some ice chips. Which of the following actions should the nurse take?

Choice A reason: Bradycardia is not typically associated with gastrointestinal perforation. While changes in heart rate can occur with severe pain or shock, it is not a primary indicator of perforation in peptic ulcer disease.

Choice B reason: This is the correct answer. Sudden abdominal pain, especially if severe and accompanied by signs of peritonitis, is a key indicator of gastrointestinal perforation. This condition requires immediate medical intervention to prevent serious complications.

Choice C reason: Hyperactive bowel sounds are more commonly associated with other gastrointestinal conditions, such as obstruction or gastroenteritis. In the case of perforation, bowel sounds may actually be diminished or absent.

Choice D reason: Increased blood pressure might occur as a response to severe pain or stress but is not a specific indicator of gastrointestinal perforation. The focus should be on abdominal symptoms and signs of acute abdomen.

Choice A reason:

Repositioning the client at least every 2 hours is a standard intervention to prevent further pressure ulcers and promote healing of existing ones. This practice helps alleviate pressure on vulnerable areas, improving blood circulation and reducing the risk of tissue breakdown.

Choice B reason:

Cleaning the wound with hydrogen peroxide solution is not recommended for pressure ulcers as it can damage healthy tissue and delay wound healing. Alternative wound cleaning solutions that are less harsh should be used to promote a more conducive healing environment.

Choice C reason:

Massaging reddened areas with dressing changes is contraindicated as it can exacerbate tissue damage and increase the risk of further ulceration. Gentle handling and appropriate wound care are essential to prevent additional harm to the affected areas.

Choice D reason:

Applying a heat lamp twice a day is not a standard or recommended practice for treating pressure ulcers. Heat can increase the risk of burns and further tissue damage. Proper wound care, including maintaining a clean and moist wound environment, is more effective for healing.