the nurse is caring for a client who has had a gastroscopy which of the following symptoms may indicate that the client is developing a complication r
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Nursing Elites

ATI RN

ATI Gastrointestinal System

1. The nurse is caring for a client who has had a gastroscopy. Which of the following symptoms may indicate that the client is developing a complication related to the procedure? Select all that apply.

Correct answer: B

Rationale: A temperature of 100°F, epigastric pain, and hematemesis are signs that may indicate a complication related to the gastroscopy procedure.

2. Kevin has a history of peptic ulcer disease and vomits coffee-ground emesis. What does this indicate?

Correct answer: C

Rationale: Coffee-ground emesis is a sign of upper gastrointestinal bleeding that occurred approximately 2 hours earlier. It results from the breakdown of blood in the stomach due to digestive enzymes, giving it a coffee-ground appearance. Choice A is incorrect because coffee-ground emesis indicates older, partially digested blood, not fresh active bleeding. Choice B is incorrect as gastric lavage is not indicated for coffee-ground emesis. Choice D is incorrect because a transfusion of packed RBCs is not the immediate management for this presentation.

3. The nurse is reviewing the physician’s orders written for a client admitted with acute pancreatitis. Which physician order would the nurse question if noted on the client’s chart?

Correct answer: D

Rationale: Morphine for pain should be questioned as it can cause spasms of the sphincter of Oddi, worsening pancreatitis.

4. You’re patient is complaining of abdominal pain during assessment. What is your priority?

Correct answer: A

Rationale: When a patient is complaining of abdominal pain, the priority is to auscultate to determine changes in bowel sounds.

5. Which nursing measure would be most effective in helping the client cough and deep breathe after a cholecystectomy?

Correct answer: C

Rationale: After a cholecystectomy, teaching the client to use a folded blanket or pillow to splint the incision will be most effective in helping the client cough and deep breathe. This technique provides support and reduces pain during coughing and deep breathing, promoting better lung expansion. Having the client take rapid, shallow breaths would not be effective in decreasing pain; instead, deep breathing is encouraged to prevent complications like atelectasis. Lying on the left side would limit lung expansion; therefore, the client should be positioned in semi-Fowler's or Fowler's position to maximize lung expansion. Withholding pain medication can lead to discomfort and reluctance to cough and deep breathe, hindering recovery.

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