the hospitalized client with gerd is complaining of chest discomfort that feels like heartburn following a meal after administering an ordered antacid
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Nursing Elites

ATI RN

ATI Gastrointestinal System

1. The hospitalized client with GERD is complaining of chest discomfort that feels like heartburn following a meal. After administering an ordered antacid, the nurse encourages the client to lie in which of the following positions?

Correct answer: C

Rationale: Lying on the left side with the head of the bed elevated 30 degrees helps prevent reflux by keeping stomach contents from moving up into the esophagus.

2. Michael, a 42 y.o. man is admitted to the med-surg floor with a diagnosis of acute pancreatitis. His BP is 136/76, pulse 96, Resps 22 and temp 101. His past history includes hyperlipidemia and alcohol abuse. The doctor prescribes an NG tube. Before inserting the tube, you explain the purpose to patient. Which of the following is a most accurate explanation?

Correct answer: A

Rationale: Explain to the patient that the NG tube is used to empty the stomach of fluids and gas, which helps relieve symptoms of acute pancreatitis.

3. A nurse is performing an assessment on a client with a suspected diagnosis of acute pancreatitis. The nurse assesses the client, knowing that which of the following is a hallmark sign of this disorder?

Correct answer: B

Rationale: A hallmark sign of acute pancreatitis is severe abdominal pain that is not relieved by vomiting. Nausea and vomiting are common presenting symptoms, with vomitus typically consisting of gastric and duodenal contents. Hypothermia is not a hallmark sign of acute pancreatitis. Fever, typically less than 38 degrees centigrade, is more common. Epigastric pain radiating to the neck area is not a characteristic sign of acute pancreatitis. Therefore, choice B is the correct answer.

4. The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis. The client is scheduled for surgery for 2 hours. The client begins to complain of increases abdominal pain and begins to vomit. On assessment the nurse notes that the abdomen distended and bowel sounds are diminished. Which of the following is the most appropriate nursing intervention?

Correct answer: B

Rationale: Based on the signs and symptoms presented in the question, the nurse should suspect peritonitis and should notify the physician. Administering pain medication is not an appropriate intervention. Heat should never be applied to the abdomen of a client with suspected appendicitis. Scheduling surgical time is not within the scope of nursing practice, although the physician probably would perform the surgery earlier than the prescheduled time.

5. Anna is 45 y.o. and has a bleeding ulcer. Despite multiple blood transfusions, her HGB is 7.5g/dl and HCT is 27%. Her doctor determines that surgical intervention is necessary and she undergoes partial gastrectomy. Postoperative nursing care includes:

Correct answer: D

Rationale: Postoperative care for a patient who underwent partial gastrectomy includes keeping her NPO until the return of peristalsis to prevent complications.

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