before bowel surgery lee is to administer enemas until clear during administration he complains of intestinal cramps what do you do next before bowel surgery lee is to administer enemas until clear during administration he complains of intestinal cramps what do you do next
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Nursing Elites

ATI RN

ATI Gastrointestinal System Test

1. Before bowel surgery, Lee is to administer enemas until clear. During administration, he complains of intestinal cramps. What do you do next?

Correct answer: B

Rationale: If a patient complains of intestinal cramps during an enema, lowering the height of the enema container can help reduce discomfort.

2. What is the priority nursing action when a patient with chest pain presents with possible acute coronary syndrome?

Correct answer: A

Rationale: The priority nursing action when a patient with chest pain presents with possible acute coronary syndrome is to administer sublingual nitroglycerin. Sublingual nitroglycerin helps dilate blood vessels, reducing cardiac workload, and improving blood supply to the heart muscle, thus relieving pain and enhancing blood flow to the heart. While obtaining IV access is important for administering medications and fluids, it is not the priority over addressing pain and improving blood flow. Checking the patient's cardiac enzymes is crucial for diagnosis and ongoing management but not the immediate priority when the patient is in pain. Administering aspirin is also a vital intervention in acute coronary syndrome, but in this scenario, it is not the priority action compared to providing immediate pain relief and enhancing blood flow to the heart.

3. A child who has just had definitive repair of a high rectal malformation is to be discharged. What should the nurse address in the discharge preparation of this family?

Correct answer: D

Rationale: Postoperative care should focus on monitoring changes in stooling patterns, which could indicate complications such as stenosis or obstruction. It is crucial to educate the family on the importance of promptly reporting any changes in stooling patterns to the healthcare provider. Options A and B are not recommended unless specifically ordered by the physician as they can potentially cause harm or discomfort postoperatively. Option C may not be appropriate immediately after surgery and should be guided by the healthcare provider's recommendations.

4. Which of the following mediators of inflammation causes increased capillary permeability and pain?

Correct answer: C

Rationale: Bradykinin is the correct answer. It is a potent mediator of inflammation that causes increased capillary permeability and is responsible for the pain associated with inflammation. Serotonin and histamine are also mediators of inflammation, but they are not primarily known for increasing capillary permeability or inducing pain. Nitric oxide is involved in various physiological processes but is not a primary mediator of inflammation that causes increased capillary permeability and pain.

5. A client with hypertension is being educated by a nurse about a heart-healthy diet. Which of the following statements indicates that the client understands the teaching?

Correct answer: C

Rationale: The correct answer is C. Limiting daily sodium intake to 3 grams is crucial in managing blood pressure and is a fundamental aspect of a heart-healthy diet. High sodium intake can contribute to hypertension and cardiovascular issues. Choices A, B, and D are incorrect because getting 15% of daily calories from saturated fats, decreasing potassium intake, and eating five servings of fruit do not directly address the management of hypertension through sodium restriction.

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