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Author Question: A client has a pyloric obstruction and reports sudden muscle weakness. What action by the nurse ... (Read 18 times)

OSWALD

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A client has a pyloric obstruction and reports sudden muscle weakness. What action by the nurse takes priority?
 
  a. Document the findings in the chart.
  b. Request an electrocardiogram (ECG).
  c. Facilitate a serum potassium test.
  d. Place the client on bedrest.

Question 2

The nurse is caring for a client with peptic ulcer disease who reports sudden onset of sharp abdominal pain. On palpation, the client's abdomen is tense and rigid. What action takes priority?
 
  a. Administer the prescribed pain medication.
  b. Notify the health care provider immediately.
  c. Percuss all four abdominal quadrants.
  d. Take and document a set of vital signs.



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medine

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Answer to Question 1

ANS: B
Pyloric stenosis can lead to hypokalemia, which is manifested by muscle weakness. The nurse first obtains an ECG because potassium imbalances can lead to cardiac dysrhythmias. A potassium level is also warranted, as is placing the client on bedrest for safety. Documentation should be thorough, but none of these actions takes priority over the ECG.

Answer to Question 2

ANS: B
This client has manifestations of a perforated ulcer, which is an emergency. The priority is to get the client medical attention. The nurse can take a set of vital signs while someone else calls the provider. The nurse should not percuss the abdomen or give pain medication since the client may need to sign consent for surgery.





 

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