A patient with a gastric outlet obstruction has been treated with NG decompression. After the first 24 hours, the patient develops nausea and increased upper abdominal bowel sounds. What is the best action by the nurse?
Check the patency of the NG tube.
Place the patient in a recumbent position.
Encourage the patient to deep breathe and consciously relax.
Assess the patient's vital signs and circulatory status.
The Correct Answer is D
The development of nausea and increased upper abdominal bowel sounds after 24 hours of NG decompression in a patient with gastric outlet obstruction raises concerns for possible complications or changes in the patient's condition. Assessing the patient's vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, can provide important information about their circulatory status and overall stability.
While checking the patency of the NG tube is important, it is not the best immediate action in this situation. The nurse should first assess the patient's vital signs to ensure their stability before proceeding with further interventions.
Placing the patient in a recumbent position (lying down) or encouraging deep breathing and conscious relaxation may not address the underlying issue and could potentially exacerbate the symptoms. It is essential to assess the patient's vital signs and circulatory status to determine the appropriate course of action.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
After rhinoplasty, nasal packing is often used to control bleeding and provide support to the nasal structures. Nasal packing can cause oral dryness, as it obstructs the normal airflow through the nasal passages, leading to mouth breathing. Mouth breathing, in turn, can cause dryness of the oral mucosa and throat, resulting in the sensation of dryness and the need to swallow frequently.
While bleeding is a possible complication after rhinoplasty, the patient's symptom of frequent swallowing is more indicative of oral dryness rather than bleeding.
Although adverse reactions to analgesics can occur, frequent swallowing is not a common symptom associated with analgesic adverse reactions. Other signs such as rash, difficulty breathing, or changes in vital signs would be more typical in case of an adverse reaction. Swallowing can be a normal response to surgery, but in this scenario, the most likely cause is the oral dryness caused by the nasal packing rather than a direct response to the analgesic.
Correct Answer is D
Explanation
To calculate the milliliters per hour (mL/hr) for the IV infusion, you divide the total volume (in milliliters) by the total time (in hours).
In this case, the total volume is 1 liter, which is equal to 1000 milliliters, and the total time is 6 hours.
So, you divide 1000 mL by 6 hours:
1000 mL / 6 hours = 166.67 mL/hr
Rounding off, the nurse will program the IV infusion device to infuse at approximately 167 mL/hr.
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