the nurse is caring for a client with a diagnosis of cirrhosis and is monitoring the client for signs of portal hypertension which initial sign if not
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Nursing Elites

ATI RN

ATI Gastrointestinal System

1. The nurse is caring for a client with a diagnosis of cirrhosis and is monitoring the client for signs of portal hypertension. Which initial sign, if noted in the client, indicates the presence of portal hypertension?

Correct answer: D

Rationale: Clinical signs and symptoms or portal hypertension are identical to those of heart failure and include jugular vein distention, lung crackles, and decreased perfusion to all organs. Initially, the client may have hypertension, flushed skin, and a bounding pulse.

2. Which of the following tests should be administered to a client suspected of having diverticulosis?

Correct answer: B

Rationale: A barium enema is a diagnostic test used to visualize the colon and can help diagnose diverticulosis.

3. The nurse is preparing to discontinue a client’s nasogastric tube. The client is positioned properly, and the tube has been flushed with 15 mL of air to clear secretions. Before removing the tube, the nurse makes which statement to the client?

Correct answer: C

Rationale: The client should take a deep breath because the client’s airway will be obstructed temporarily during tube removal. The nurse then tells the client to exhale slowly and withdraws the tube during exhalation. Bearing down could inhibit the removal of the tube. Breathing normally could result in aspiration of gastric secretions during inhalation. Holding the breath does not facilitate tube removal.

4. A client with rectal cancer may exhibit which of the following symptoms?

Correct answer: C

Rationale: Rectal bleeding is a common symptom in clients with rectal cancer.

5. 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.

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