NCLEX-RN

Category - Basic Care

After performing a gastric lavage on a client with gastric bleeding due an ulcer, which of the following steps is the most important for the nurse to accomplish?
  1. Measure intake and output accurately.
  2. Measure vital signs frequently.
  3. Save the contents for further testing.
  4. Withdraw blood to determine arterial blood gas (ABG) levels.
Explanation
Answer: D - The most important step after a gastric lavage is to monitor for fluid and electrolyte imbalance, which is done by withdrawing blood for testing. ABG checks for metabolic alkalosis, caused by the removal of gastric juices. Measuring vital signs, intake and output, and saving the gastric contents for further tests are important, but none are as significant as option D.
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