the client being treated for esophageal varices has a sengstaken blakemore tube inserted to control the bleeding the most important assessment is for
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Nursing Elites

ATI RN

ATI Gastrointestinal System

1. The client being treated for esophageal varices has a Sengstaken-Blakemore tube inserted to control the bleeding. The most important assessment is for the nurse to:

Correct answer: C

Rationale: Regularly assessing respiratory status is crucial when a Sengstaken-Blakemore tube is inserted to control bleeding in esophageal varices.

2. You’re caring for Jane, a 57 y.o. patient with liver cirrhosis who develops ascites and requires paracentesis. Before her paracentesis, you instruct her to:

Correct answer: A

Rationale: Before paracentesis, instruct the patient to empty her bladder to avoid bladder injury during the procedure.

3. A nurse is developing a teaching plan for the client with viral hepatitis. The nurse plans to tell the client which of the following in the teaching session?

Correct answer: A

Rationale: The client with viral hepatitis should limit activity to avoid fatigue during the recuperation period. The diet should be optimal in calories, proteins, and carbohydrates. The client should take in several small meals per day. Alcohol is strictly forbidden.

4. A nurse is reviewing the orders of a client admitted to the hospital with a diagnosis of acute pancreatitis. Select the interventions that the nurse would expect to be prescribed for the client.

Correct answer: B

Rationale: The correct intervention for a client with acute pancreatitis is to prescribe pain medications such as meperidine to manage the abdominal pain, which is a prominent symptom of the condition. The other options are incorrect because: A) Clients with acute pancreatitis are normally placed on NPO (nothing by mouth) status to rest the pancreas, so small, frequent high-calorie feedings are not indicated. C) Placing the client in a side-lying position with the head elevated 45-degrees helps decrease tension on the abdomen and may ease pain, but it is not a standard intervention for acute pancreatitis. D) Administering antacids and anticholinergics to suppress gastrointestinal secretions is not a routine intervention for acute pancreatitis.

5. Cholestyramine resin (Questran Light) is prescribed for the client with an elevated serum cholesterol level. The nurse would instruct the client to take the medication

Correct answer: B

Rationale: Cholestyramine resin binds with bile salts in the intestines to form a compound that is excreted in the feces. The client should be instructed to mix the medication with 3 to 6 oz of water, milk, fruit juice, or soup. The medication should be administered before meals. The medication is not administered via rectal suppository.

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