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. Which of the following interventions promotes patient safety?

Correct answer: D

Rationale: All the listed interventions are essential for promoting patient safety. Assessing the patient’s ability to ambulate and transfer helps prevent falls, demonstrating the signal system ensures effective communication in emergencies, and checking the patient's identification band aids in accurate identification and treatment. By combining these interventions, healthcare providers can enhance patient safety and quality of care.

3. To assess the kidney function of a patient with an indwelling urinary (Foley) catheter, the nurse measures the hourly urine output. When should she notify the physician?

Correct answer: A

Rationale: Notifying the physician is necessary when the urine output is less than 30 ml/hour as it indicates impaired kidney function. Adequate urine output is essential for monitoring kidney function, and a urine output less than 30 ml/hour could suggest potential renal issues that require medical attention.

4. Which of the following signs and symptoms would the nurse expect to find when assessing an Asian patient for postoperative pain following abdominal surgery?

Correct answer: C

Rationale: Immobility, diaphoresis, and avoidance of deep breathing or coughing are common signs of pain.

5. If a patient asks the nurse for her opinion about a particular physician and the nurse replies that the physician is incompetent, the nurse could be held liable for:

Correct answer: A

Rationale: In this scenario, if the nurse makes a false verbal statement about the physician being incompetent, it is considered slander. Slander is the act of making defamatory spoken statements or gestures. Libel, on the other hand, refers to defamatory statements that are written or published. Assault involves the threat of physical harm, and respondent superior is a legal doctrine holding an employer responsible for the actions of an employee in the course of employment.

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