A patient just returned to the surgical unit after a gastric bypass.
What action by the nurse is the priority?

Choice A rationale

Abdominal distention, anxiety, discomfort, and bloating in a patient with an NG tube on low gastric suction suggest that the tube is not functioning correctly. The most immediate and priority action is to check for proper function and patency. The suction equipment may be disconnected, the canister may be full, or the tube itself may be kinked or clogged. Resolving the mechanical issue will relieve the patient's symptoms.

Choice B rationale

Irrigating a non-functioning NG tube with 100 mL of sterile water is an inappropriate volume and can cause further distention and discomfort. Standard practice for irrigating an NG tube is with a much smaller volume, typically 30 mL of normal saline, to prevent electrolyte imbalances and excessive gastric distention. This action would not address the root cause of the patient's symptoms and could be harmful.

Choice C rationale

Removing and reinserting the NG tube should only be done if other troubleshooting methods fail to restore function. This is an invasive procedure that can be uncomfortable for the patient and is not the first step in addressing a potential obstruction or equipment malfunction. A thorough assessment of the system should be performed before considering a reinsertion.

Choice D rationale

Requesting a prescription for an anxiety medication does not address the physiological cause of the patient's distress. The patient's anxiety and discomfort are likely a direct result of the unresolved abdominal distention and bloating. Treating the underlying physical cause by ensuring the NG tube is working correctly is the priority intervention to provide relief.

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.