after abdominal surgery your patient has a severe coughing episode that causes wound evisceration in addition to calling the doctor which intervention
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Nursing Elites

ATI RN

ATI Gastrointestinal System Test

1. After abdominal surgery, your patient has a severe coughing episode that causes wound evisceration. In addition to calling the doctor, which intervention is most appropriate?

Correct answer: B

Rationale: Covering the wound with a saline soaked sterile dressing is the most appropriate intervention for wound evisceration.

2. The client is admitted to the hospital for treatment of acute hepatitis B. Which activity order would the nurse expect to be prescribed?

Correct answer: A

Rationale: Fatigue is a normal response to hepatic cellular damage. During the acute stage, rest is an essential intervention to reduce the metabolic demands on the liver and its blood supply.

3. A nurse is preparing to remove a nasogastric tube from a client. The nurse would instruct the client to do which of the following just before the nurse removes the tube?

Correct answer: B

Rationale: When the nurse removes a nasogastric tube, the client is instructed to take and hold a deep breath. This will be obstructed temporarily during the tube removal. This allows for easy withdrawal through the esophagus into the nose. The nurse removes the tube with one smooth, continuous pull.

4. A client with viral hepatitis states, 'I am so yellow.' The nurse most appropriately would

Correct answer: A

Rationale: To assist the client in adapting to changes in appearance, the nurse must encourage participation in self-care to foster independence and self-esteem. The nurse should encourage the client to ask questions to clarify misconceptions, learn ways to prevent the spread of hepatitis to reduce fear, and make appropriate decisions. Restricting visitors will reinforce the client’s negative self-esteem.

5. You’re caring for Beth who underwent a Billroth II procedure (surgical removal of the pylorus and duodenum) for treatment of a peptic ulcer. Which findings suggest that the patient is developing dumping syndrome, a complication associated with this procedure?

Correct answer: C

Rationale: Dizziness and sweating are common signs of dumping syndrome, a complication of the Billroth II procedure.

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