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

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?

A. Instill 500 ml of solution through the NG tube.
B. Insert a large-bore NG tube.
C. Use a cold irrigation solution.
D. Instruct the client to lie on their right side.

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 healthcare professional in an emergency department is assessing a newly admitted client who is experiencing drooling and hoarseness following a burn injury. Which of the following actions should the healthcare professional take first?

A. Obtain a baseline ECG.
B. Obtain a blood specimen for ABG analysis.
C. Insert an 18-gauge IV catheter.
D. Administer 100% humidified oxygen.

Correct answer: D

Rationale: In a client experiencing drooling and hoarseness following a burn injury, airway compromise is a critical concern. Administering 100% humidified oxygen is the priority to ensure adequate oxygenation. This intervention takes precedence over obtaining baseline ECG, obtaining blood specimens, or inserting an IV catheter, as airway management and oxygenation are fundamental in the initial assessment and management of a client with potential airway compromise.

3. Which of the following white blood cell (WBC) counts clearly indicates leukocytosis?

A. 4,500/mmÂ³
B. 7,000/mmÂ³
C. 10,000/mmÂ³
D. 25,000/mmÂ³

Correct answer: D

Rationale: Leukocytosis is defined as an increase in the total white blood cell count. A normal WBC count typically ranges from 4,500 to 10,000/mmÂ³. A WBC count of 25,000/mmÂ³, as indicated in choice D, is significantly higher than the normal range and clearly indicates leukocytosis.

4. How many liters are equal to 1800 ml?

A. 1.8
B. 18000
C. 180
D. 2800

Correct answer: A

Rationale: To convert milliliters (ml) to liters, divide by 1000 since 1 liter is equal to 1000 ml. Therefore, 1800 ml is equal to 1800/1000 = 1.8 liters. Choice A (1.8) is correct. Choice B (18000) is incorrect as it equates to 18000 liters, not 1.8 liters. Choice C (180) is incorrect as it represents 180 liters, not 1.8 liters. Choice D (2800) is incorrect as it does not reflect the conversion of 1800 ml to liters.

5. What is the primary purpose of handwashing?

A. To promote hand circulation
B. To prevent the transfer of microorganisms
C. To avoid touching the client with a dirty hand
D. To provide comfort

Correct answer: B

Rationale: The primary purpose of handwashing is to prevent the transfer of microorganisms. Proper hand hygiene helps reduce the risk of spreading harmful bacteria and viruses, thus promoting overall health and preventing infections. Choice A is incorrect as handwashing primarily focuses on cleanliness rather than promoting circulation. Choice C is incorrect as it implies that the main concern is avoiding client discomfort rather than preventing infection. Choice D is incorrect as while handwashing can be comforting in some situations, its primary purpose is not to provide comfort but to maintain hygiene.