a nurse is preforming a gastric lavage for a client who has upper gastrointestinal bleeding which of the following action should the nurse take
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Nursing Elites

ATI RN

ATI Fundamentals Proctored Exam 2023

1. A healthcare provider is performing a gastric lavage for a client who has upper gastrointestinal bleeding. Which of the following actions should the healthcare provider take?

Correct answer: B

Rationale: During a gastric lavage procedure for upper gastrointestinal bleeding, inserting a large-bore NG tube is essential to effectively remove gastric contents and blood. This tube allows for efficient irrigation and suction, aiding in the removal of harmful substances from the stomach. Instilling a large volume of solution or using a cold irrigation solution can lead to complications such as fluid overload or hypothermia. Instructing the client to lie on their right side is not directly related to the gastric lavage procedure.

2. A caregiver is caring for a 5-month-old infant who has manifestations of severe dehydration and a prescription for parenteral fluid therapy. The caregiver asks, 'What are the indications that my baby needs an IV?' Which of the following responses should the caregiver make?

Correct answer: A

Rationale: The correct response is A: 'Your baby needs an IV because she is not producing any tears.' In infants, the inability to produce tears is a sign of severe dehydration. This is a crucial indication for the need for intravenous (IV) fluid therapy to rehydrate the infant. While the other options may also be symptoms of dehydration, the absence of tears is a more direct and specific indicator requiring immediate attention and intervention.

3. A client reports that the medication the nurse is administering appears different than what they take at home. Which of the following responses should the nurse take?

Correct answer: A

Rationale: When a client reports that the medication appears different than what they take at home, it is crucial for the nurse to ensure the safety and accuracy of the medication being administered. The most appropriate action for the nurse to take in this situation is to call the pharmacist to verify the medication, dosage, and any potential changes. This proactive step helps prevent medication errors and ensures the client's safety and well-being.

4. Which technique in physical examination is used to assess the movement of air through the tracheobronchial tree?

Correct answer: B

Rationale: The correct answer is B: Auscultation. Auscultation is a technique in physical examination used to assess the movement of air through the tracheobronchial tree. During auscultation, healthcare providers listen to lung sounds using a stethoscope to detect abnormalities such as wheezing, crackles, or diminished breath sounds, which can indicate conditions affecting the airways or lungs. Palpation (Choice A) involves feeling the body for abnormalities, Inspection (Choice C) involves visual examination, and Percussion (Choice D) involves tapping on the body to produce sounds that can help in assessing underlying structures, but they are not directly used to assess air movement through the tracheobronchial tree.

5. Parenteral penicillin can be administered as an:

Correct answer: A

Rationale: Penicillin can be administered intramuscularly or intravenously.

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