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. A client is recovering from an ileostomy that was performed to treat inflammatory bowel disease. During discharge teaching for this client, the nurse should stress:

Correct answer: A

Rationale: The correct answer is A: increasing fluid intake to prevent dehydration. An ileostomy typically drains liquid waste, so the client is at risk of fluid loss. By increasing fluid intake, the client can prevent dehydration. It's essential for the client to wear a collection appliance at all times because ileostomy drainage is incontinent. Consuming a low-protein, high-fiber diet is not recommended as high-fiber foods can cause intestinal irritation. Enteric-coated medications should be avoided because they may not be absorbed properly after an ileostomy.

3. To prevent gastroesophageal reflux in a client with hiatal hernia, the nurse should provide which discharge instructions?

Correct answer: B

Rationale: To prevent reflux of stomach acid into the esophagus, the nurse should advise the client to avoid foods and beverages that tend to increase stomach acid, such as coffee and alcohol. The nurse also should teach the client to avoid lying down after meals, which can aggravate reflux, and to take antacids after eating. The client doesn't need to limit fluids with meals as long as the fluids aren't gastric irritants.

4. The nurse is caring for a hospitalized client with a diagnosis of ulcerative colitis. Which finding, if noted on assessment of the client, would the nurse report to the physician?

Correct answer: D

Rationale: Rebound tenderness is a sign of peritonitis, a serious complication that needs to be reported to the physician immediately.

5. A client with peptic ulcer is scheduled for a Vagotomy. The client asks the nurse about the purpose of this procedure. The nurse tells the client that the procedure

Correct answer: D

Rationale: A vagotomy, or cutting of the vagus nerve, is done to eliminate parasympathetic stimulation of gastric secretion, thereby reducing the stimulus to acid secretions. Options A, B, and C are incorrect as a vagotomy does not affect food absorption, heal the gastric mucosa, or halt stress reactions.

Similar Questions

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