the client with cirrhosis has ascites and excess fluid volume which measure will the nurse include in the plan of care for this client the client with cirrhosis has ascites and excess fluid volume which measure will the nurse include in the plan of care for this client
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Nursing Elites

ATI RN

Gastrointestinal System Nursing Exam Questions

1. The client with cirrhosis has ascites and excess fluid volume. Which measure will the nurse include in the plan of care for this client?

Correct answer: B

Rationale: Excess fluid volume, related to the accumulation of fluid in the peritoneal and dependent areas of the body, can occur in the client with cirrhosis. Fluids should be restricted, including fluids given in medications and meals. Sodium restriction also aids in reducing fluid volume excess.

2. A client who has burn injuries covering their upper body is concerned about their altered appearance. Which of the following statements should the nurse make?

Correct answer: D

Rationale: The nurse should encourage the client to attend a support group for individuals who have burn injuries. Support groups can provide emotional support, shared experiences, and coping strategies for accepting their altered appearance. Choice A is not the best response as it does not offer proactive support. Choice B is not appropriate as the timing of cosmetic surgery should be determined by healthcare providers, not immediate. Choice C is misleading as reconstructive surgery may improve appearance but may not completely restore the previous look.

3. The charge nurse in the pediatric unit is teaching nursing students about pyloric stenosis. A student asks what causes pyloric stenosis. How should the nurse respond?

Correct answer: B

Rationale: Pyloric stenosis is caused by the hypertrophy (thickening) of the circular muscle of the pylorus, leading to obstruction. Choice A is incorrect as it describes intussusception, not pyloric stenosis. Choice C is incorrect as a relaxed cardiac sphincter is related to gastroesophageal reflux. Choice D is incorrect as it describes Hirschsprung's disease, not pyloric stenosis.

4. The nurse is performing a colostomy irrigation on a client. During the irrigation, a client begins to complain of abdominal cramps. Which of the following is the most appropriate nursing action?

Correct answer: C

Rationale: If a client experiences abdominal cramps during a colostomy irrigation, it is appropriate to stop the irrigation temporarily to allow the cramps to subside.

5. During an in-service about nursing leadership, what information should the nurse include about an effective leader?

Correct answer: A

Rationale: An effective leader advocates for the unit's success and its members. Choice B is incorrect because prioritizing staff requests over client needs does not align with effective leadership, which should focus on client-centered care. Choice C is incorrect as sharing personal opinions to influence the group's values can be biased and may not reflect the best interest of the team. Choice D is incorrect because while providing client care is essential, effective leadership involves more than routine tasks and includes guiding and supporting the team.

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