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 techniques would the nurse use first to determine if a nasogastric tube is positioned in the stomach?

Correct answer: A

Rationale: The initial way to determine if a nasogastric tube is in the stomach is to apply suction to the tube with a syringe and observe for the return of stomach contents. Then the pH of the aspirate can be measured. This is the method of choice. One would not irrigate until tube placement is confirmed. Observing for air bubbles when the free end of the tube is placed under water is an unacceptable, unsafe method of determining tube placement. Another method is to instill air into the tube with a syringe while auscultating over the epigastric area. Hearing the air enter the stomach helps ensure proper placement, but the method is not foolproof and is no longer considered an effective or preferred way to determine placement.

3. 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?

Correct answer: B

Rationale: Monitoring the client's vital signs and notifying the physician of the client's symptoms are crucial actions based on the reported symptoms.

4. The nurse is irrigating a client's colostomy when she complains of abdominal cramping after receiving about 100 mL of the irrigating solution. What should the nurse's first response be in this situation?

Correct answer: A

Rationale: The abdominal cramping that can occur during colostomy irrigation results from stimulation of the colon by the irrigating solution. The nurse's first response should be to temporarily stop the flow of solution to allow the cramping to subside. Repositioning the client to the right side will not alleviate the cramping. Removing the tube will not decrease the cramping and will necessitate reinsertion of the tube when the irrigation is resumed. Massaging the abdomen gently may be soothing to some clients, but it is not the nurse's first priority action.

5. Your goal is to minimize David’s risk of complications after a heriorrhaphy. You instruct the patient to:

Correct answer: C

Rationale: Instruct the patient to splint the incision if he can't avoid sneezing or coughing to minimize the risk of complications after heriorrhaphy.

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