A patient admitted with a peptic ulcer has a nasogastric (NG) tube in place. When the patient develops sudden, severe upper abdominal pain, diaphoresis, and a firm abdomen, which action should the nurse take?
Irrigate the NG tube.
Elevate the foot of the bed.
Give the ordered antacid.
Check the vital signs.
The Correct Answer is D
The nurse should quickly assess the patient's vital signs to check for signs of shock and instability. If the vital signs are unstable, the nurse should initiate appropriate interventions to stabilize the patient, such as administering oxygen, starting IV fluids, and providing continuous cardiac monitoring. Based on the sudden onset of severe upper abdominal pain, diaphoresis, and a firm abdomen, the nurse should suspect a possible perforation or bleeding related to the peptic ulcer. This is a medical emergency that requires immediate intervention. Therefore, the nurse should prioritize notifying the healthcare provider and preparing the patient for urgent medical evaluation.
Option A, irrigating the NG tube, is not appropriate in this situation and may further exacerbate the patient's condition if the ulcer has perforated.
Option B, elevating the foot of the bed, is also not appropriate as it does not address the patient's current symptoms.
Option C, giving the ordered antacid, may not be effective in addressing the severity of the patient's symptoms and should be postponed until the healthcare provider has evaluated the patient.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
Option A indicates that the client understands the timing of glyburide administration, which is typically taken with the first bite of a meal to aid in glucose control.
Option d indicates that the client understands the importance of continuing antidiabetic medications even when they are sick. Skipping doses during illness can lead to uncontrolled blood glucose levels.
Option e indicates that the client understands the importance of foot care in preventing complications related to peripheral neuropathy, such as diabetic foot ulcers.
Option b is incorrect because patients with peripheral neuropathy should not walk barefoot, as they may not feel injuries to their feet, which can lead to diabetic foot ulcers and other complications.
Option c is incorrect because antidiabetic medications do not allow patients to eat whatever they desire. Patients with diabetes need to follow a healthy diet and exercise plan to manage their blood glucose levels effectively.
Correct Answer is C
Explanation
Nausea and vomiting are common symptoms of early pregnancy, and abdominal pain can also occur due to various pregnancy-related conditions. Therefore, it is essential to rule out pregnancy as a potential cause of the patient's symptoms before pursuing other diagnostic options.
Once pregnancy has been ruled out, the nurse can ask additional questions such as those listed in options a, b, and d to further narrow down the potential causes of the patient's symptoms.
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