the nurse is assessing a client 24 hours following a cholecystectomy the nurse notes that the t tube has drained 750ml of green brown drainage which n
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Nursing Elites

ATI RN

ATI Gastrointestinal System

1. The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750ml of green-brown drainage. Which nursing intervention is most appropriate?

Correct answer: B

Rationale: Documenting the findings is the most appropriate action as 750ml of green-brown drainage is expected after a cholecystectomy.

2. A client with liver dysfunction has low serum levels of thrombin. The nurse provides care, anticipating that this client is most at risk of

Correct answer: C

Rationale: Thrombin is produced by the liver and is necessary for normal clotting. When a client with liver dysfunction has low serum levels of thrombin, they are at risk of bleeding due to impaired clotting mechanisms. Dehydration (choice A) is not directly related to low thrombin levels. Malnutrition (choice B) may impact overall health but is not the most immediate concern associated with low thrombin levels. Infection (choice D) is not directly related to the clotting function affected by low thrombin levels.

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. Vasopressin (Pitressin) therapy is prescribed for a client with a diagnosis of bleeding esophageal varices. The nurse is preparing to administer the medication to the client. Which of the following essential items is needed during the administration of this medication?

Correct answer: A

Rationale: The major action of vasopressin is constriction of the splanchnic blood flow. Continuous electrocardiogram and blood pressure monitoring are essential because of the constrictive effects of the medication on the coronary arteries. Options 2, 3, and 4 are not essential items required during the administration of this medication.

5. Care for the postoperative client after gastric resection should focus on which of the following problems?

Correct answer: B

Rationale: Postoperative care after gastric resection should focus on the client's nutritional needs to ensure proper healing and recovery.

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