The emergency room nurse is caring for a client just diagnosed with a bowel obstruction secondary to adhesions. Which of the following orders should the nurse complete first?
Hang IV fluids of CSNS with 20 mEq of potassium chloride at 125 ml/hr
Insert a nasogastric tube
Draw a basic metabolic panel
Ambulate in the hallway
The Correct Answer is B
A. Hang IV fluids of CSNS with 20 mEq of potassium chloride at 125 ml/hr: Fluid resuscitation is important, but potassium should not be administered until electrolyte levels are assessed. Also, potassium administration in a client with a bowel obstruction requires caution due to the risk of hyperkalemia if renal function is impaired.
B. Insert a nasogastric tube: A nasogastric (NG) tube is essential in managing bowel obstruction as it helps decompress the stomach, relieve pressure, and prevent aspiration. This should be done first to stabilize the client.
C. Draw a basic metabolic panel: Checking electrolyte imbalances is important but should be done after stabilizing the client with NG tube insertion.
D. Ambulate in the hallway: Ambulation is contraindicated in acute bowel obstruction due to the risk of worsening symptoms such as nausea, vomiting, and severe pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Decrease levels of CEA indicate the treatment of your colon cancer was effective: CEA is a tumor marker primarily used to monitor treatment response in certain cancers, especially colorectal cancer. A decrease in CEA levels after treatment suggests a positive response and reduced tumor burden.
B. Increased levels of CEA indicate that surgery to correct your diverticulitis was effective: CEA is not used to monitor diverticulitis. It is mainly associated with cancers, particularly colorectal cancer. An increase in CEA levels suggests possible cancer recurrence or progression, not resolution of diverticulitis.
C. Increased levels of CEA indicate a return of your pancreatitis: CEA is not a marker for pancreatitis. Pancreatitis is typically monitored using amylase, lipase, and imaging studies.
D. Decreased levels of CEA indicate that you have Ulcerative Colitis: Ulcerative colitis is an inflammatory bowel disease (IBD) that is not diagnosed or monitored using CEA. While chronic inflammation may increase cancer risk over time, CEA is not a direct indicator of UC.
Correct Answer is B
Explanation
A. "Your colostomy will not produce formed stool.” A sigmoid colostomy produces formed stool because it is at the end of the large intestine, where water is absorbed.
B. "You will have a stoma in your left lower abdomen." A sigmoid colostomy is placed in the left lower quadrant (LLQ) of the abdomen.
C. "You should expect your stoma to be a purple color." A healthy stoma should be pink to red and moist. A purple, dusky, or dark-colored stoma may indicate ischemia and requires immediate evaluation.
D. "The end of the stoma will be painful after this procedure." The stoma itself does not have nerve endings, so it should not be painful. However, the surrounding abdominal incision may be sore.
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