a nurse is developing a plan of care for a client who will be returning to a nursing unit following a percutaneous transhephatic cholangiogram the nur
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Nursing Elites

ATI RN

Gastrointestinal System Nursing Exam Questions

1. A nurse is developing a plan of care for a client who will be returning to a nursing unit following a percutaneous transhephatic cholangiogram. The nurse includes which intervention in the postprocedure plan of care?

Correct answer: A

Rationale: Following this procedure, the nurse monitors the client’s vital signs closely for indications of hemorrhage and observes the needle insertion site for bleeding and bile leakage. A sandbag is placed over the insertion site to prevent bleeding. The client is maintained on bedrest, and oral intake is avoided in the immediate postprocedure period in case surgery is necessary to control hemorrhage of bile extravasation.

2. Which of the following tests can be performed to diagnose a hiatal hernia?

Correct answer: C

Rationale: A barium swallow is a diagnostic test that can visualize the esophagus, stomach, and small intestine to diagnose a hiatal hernia.

3. When teaching an elderly client how to prevent constipation, which of the following instructions should the nurse include?

Correct answer: D

Rationale: To prevent constipation, elderly clients should be encouraged to get regular exercise, which promotes bowel motility.

4. After a subtotal gastrectomy, the nurse should anticipate that nasogastric tube drainage will be what color for about 12 to 24 hours after surgery?

Correct answer: A

Rationale: Dark brown drainage is expected for about 12 to 24 hours after surgery.

5. Which of the following nursing interventions should be implemented to manage a client with appendicitis?

Correct answer: D

Rationale: The correct answer is D: Assessing for symptoms of peritonitis. This intervention is crucial in managing a client with appendicitis because it indicates a possible rupture of the inflamed appendix. Symptoms of peritonitis include severe abdominal pain, fever, nausea, vomiting, and abdominal rigidity. Prompt recognition of these symptoms is essential for timely intervention and surgical management. Choices A, B, and C are incorrect because while assessing for pain is important, assessing for symptoms of peritonitis takes precedence due to the critical nature of appendicitis. Encouraging oral intake of clear fluids and providing discharge teaching are not immediate priorities in the management of a client with acute appendicitis.

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