While caring for a client with peptic ulcer disease, the client reports that he has been nauseated most of the day and is now feeling lightheaded and dizzy. Based upon these findings, which nursing actions would be most appropriate for the nurse to take? Select all that apply.
A. Administering an antacid hourly until nausea subsides.
B. Monitoring the client’s vital signs.
C. Notifying the physician of the client’s symptoms.
D. Initiating oxygen therapy.
E. Reassessing the client in an hour.
Correct Answer: B and C.
The symptoms of nausea and dizziness in a client with peptic ulcer disease may be indicative of hemorrhage and should not be ignored. The appropriate nursing actions at this time are for the nurse to monitor the client’s vital signs and notify the physician of the client’s symptoms.
Option A: To administer an antacid hourly or to wait one hour to reassess the client would be inappropriate; prompt intervention is essential in a client who is potentially experiencing a gastrointestinal hemorrhage.
Option B: Instruct the client on what signs and symptoms to report to the health care provider. Recognizing the signs and symptoms can help ensure the early initiation of treatment. Explain the pathophysiology of disease and how it relates to the functioning of the body.
Option C: The nurse would notify the physician of assessment findings. Assess for body weight changes. Weight loss is an indication of inadequate nutritional intake. Gastric ulcers are more likely to be associated with vomiting, loss of appetite, and weight loss than duodenal ulcers.
Option D: Then the nurse would initiate oxygen therapy if ordered by the physician. Monitor laboratory values for serum albumin. This test indicates the degree of protein depletion (2.5 g/dL indicates severe depletion; 3.8 to 4.5 g/dL is normal).
Option E: Obtain a nutritional history. Clients may often overestimate the amount of food eaten. The client may not eat sufficient calories or essential nutrients as a way to reduce pain episodes with peptic ulcer disease. Because of this, clients are at high risk for malnutrition.
No comments:
Post a Comment