a client with viral hepatitis is discussing with the nurse the need to avoid alcohol and states im not sure i can avoid alcohol the most appropriate r
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Nursing Elites

ATI RN

Gastrointestinal System Nursing Exam Questions

1. A client with viral hepatitis is discussing with the nurse the need to avoid alcohol and states, 'I’m not sure I can avoid alcohol.' The most appropriate response is

Correct answer: D

Rationale: The most appropriate response in this situation is to seek clarification from the client by saying, 'I’m not sure that I don’t understand. Would you please explain?' This response shows empathy and a willingness to listen, encouraging the client to elaborate on their concerns. False reassurance (Choice A) is not helpful as it dismisses the client's feelings. Suggesting to talk more with the doctor (Choice B) may deflect from addressing the client's immediate concerns. Expressing disbelief (Choice C) can create a barrier to open communication, making the client feel unsupported.

2. The client being treated for esophageal varices has a Sengstaken-Blakemore tube inserted to control the bleeding. The most important assessment is for the nurse to:

Correct answer: C

Rationale: Regularly assessing respiratory status is crucial when a Sengstaken-Blakemore tube is inserted to control bleeding in esophageal varices.

3. The client with a colostomy has an order for irrigation of the colostomy. The nurse used which solution for irrigation?

Correct answer: B

Rationale: Tap water at body temperature is generally used for colostomy irrigation unless the local water supply is not safe for drinking, in which case bottled water can be used.

4. A client is admitted to the hospital after vomiting bright red blood and is diagnosed with a bleeding duodenal ulcer. The client develops a sudden, sharp pain in the midepigastric area along with a rigid, boardlike abdomen. These clinical manifestations most likely indicate which of the following?

Correct answer: D

Rationale: A sudden, sharp pain in the midepigastric area along with a rigid, boardlike abdomen indicates that the ulcer has perforated.

5. Vasopressin (Pitressin) therapy is prescribed for a client with a diagnosis of bleeding esophageal varices. The nurse is preparing to administer the medication to the client. Which of the following essential items is needed during the administration of this medication?

Correct answer: A

Rationale: The major action of vasopressin is constriction of the splanchnic blood flow. Continuous electrocardiogram and blood pressure monitoring are essential because of the constrictive effects of the medication on the coronary arteries. Options 2, 3, and 4 are not essential items required during the administration of this medication.

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