A patient diagnosed with small bowel obstruction (SBO) develops sudden severe abdominal pain and a rigid abdomen. What is the nurse's priority action?
Encourage the patient to ambulate to relieve discomfort.
Administer prescribed analgesics to manage the pain.
Notify the healthcare provider immediately.
Increase the intravenous fluid rate to maintain hydration.
The Correct Answer is C
Rationale:
A. Encouraging ambulation is contraindicated in a patient with sudden severe abdominal pain and a rigid abdomen. These symptoms suggest a surgical emergency, such as bowel perforation or ischemia, and movement could worsen the condition.
B. Administering analgesics may provide pain relief, but pain management is secondary to identifying and addressing the life-threatening cause. Masking symptoms could delay recognition of perforation or peritonitis.
C. Notifying the healthcare provider immediately is the priority action. Sudden severe pain and abdominal rigidity in a patient with SBO indicate a potential bowel perforation, peritonitis, or strangulation, all of which are medical emergencies requiring urgent surgical evaluation and intervention. Prompt notification ensures rapid assessment, imaging, and preparation for possible surgery.
D. Increasing IV fluid rate is important for maintaining hydration and supporting circulation, but it does not address the emergent cause of acute pain and rigidity. While IV access should be maintained, contacting the provider takes precedence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Alcohol and caffeine are well-known risk factors that worsen GERD symptoms. Both substances can decrease lower esophageal sphincter (LES) tone, allowing gastric contents to reflux into the esophagus. They can also increase gastric acid secretion and irritate the esophageal mucosa. Teaching clients to limit or avoid alcohol and caffeine is a key component of GERD education.
B. Lying down after eating does increase the risk of GERD symptoms. When a person lies flat, gravity no longer helps keep stomach contents in the stomach, making reflux more likely. Clients with GERD are advised to remain upright for at least 2–3 hours after meals and to elevate the head of the bed.
C. Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) can irritate the gastric and esophageal mucosa and may worsen GERD symptoms or increase the risk of gastrointestinal bleeding. Therefore, it is not advisable to take aspirin routinely if GERD is present unless specifically prescribed.
D. Mercury-containing foods, such as certain seafood, are not associated with GERD symptoms. Dietary triggers for GERD are related to acid production, LES relaxation, and mucosal irritation.
Correct Answer is C
Explanation
Rationale:
A. Suggesting increased caffeine intake may provide temporary stimulation, but it does not address the underlying cause of fatigue, which in this case is likely anemia due to low hemoglobin from radiation therapy. Excessive caffeine can also cause dehydration, insomnia, or palpitations, potentially worsening fatigue.
B. Encouraging exercise may improve stamina in some patients, but initiating a regular exercise program in a patient with severe anemia and low hemoglobin can increase cardiac workload and risk of complications. Exercise should be considered only after anemia is corrected or stabilized.
C. Consulting with the healthcare provider about iron supplementation or other anemia management is the most appropriate intervention. Radiation therapy can cause anemia through bone marrow suppression or bleeding, leading to fatigue. Addressing the underlying cause of low hemoglobin can help improve oxygen delivery to tissues, reduce fatigue, and enhance functional ability. The healthcare provider may recommend iron, erythropoiesis-stimulating agents, or transfusion depending on severity.
D. Advising short naps can help manage fatigue temporarily, but it is only a supportive measure. It does not treat the underlying anemia, and without addressing the low hemoglobin, the patient’s fatigue will likely persist.
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