the nurse is evaluating the plan of care for a client with peptic ulcer disease with a nursing diagnosis of acute pain the nurse would determine that
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Nursing Elites

ATI RN

ATI Gastrointestinal System

1. The nurse is evaluating the plan of care for a client with peptic ulcer disease with a nursing diagnosis of Acute Pain. The nurse would determine that the client has not met the expected outcomes if the client states

Correct answer: C

Rationale: Expected outcomes for the client with peptic ulcer disease experiencing pain include elimination of irritating foods from the diet, ability to take prescribed medications that will reduce pain, reporting that the pain is relieved or prevented with medication, and an ability to sleep through the night without pain. The client who continues to be awakened by pain requires further modification of medication therapy, which may include adjustment of timing of histamine H2 receptor antagonist or an additional dose of antacid before the time when pain awakens the client.

2. Five days after undergoing surgery, a client develops a small-bowel obstruction. A Miller-Abbott tube is inserted for bowel decompression. Which nursing diagnosis takes priority?

Correct answer: C

Rationale: For a client with a small-bowel obstruction and a Miller-Abbott tube, deficient fluid volume is the priority nursing diagnosis.

3. Which of the following aspects is the priority focus of nursing management for a client with peritonitis?

Correct answer: A

Rationale: The priority focus of nursing management for a client with peritonitis is fluid and electrolyte balance to prevent shock.

4. Which of the following measures should the nurse focus on for the client with esophageal varices?

Correct answer: A

Rationale: The primary focus for a client with esophageal varices is recognizing hemorrhage because these varices can rupture and cause significant bleeding.

5. The nurse is doing preoperative teaching with the client who is about to undergo creation of a Kock pouch. The nurse interprets that the client has the best understanding of the nature of the surgery if the client makes which of the following statements?

Correct answer: A

Rationale: A Kock pouch is a continent ileostomy. As the ileostomy begins to function, the client drains it every 3 to 4 hours and then decreases the draining about 3 times a day or as needed when full. The client does not need to wear a drainage bag but should wear an absorbent dressing to absorb mucous drainage from the stoma. Ileostomy drainage is liquid. The client would be able to pass stool only from the rectum if an ileal-anal pouch or anastomosis were created. This type of operation is a two-stage procedure.

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