the nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis the client is scheduled for surgery for 2 hours the client
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Nursing Elites

ATI RN

ATI Gastrointestinal System

1. The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis. The client is scheduled for surgery for 2 hours. The client begins to complain of increases abdominal pain and begins to vomit. On assessment the nurse notes that the abdomen distended and bowel sounds are diminished. Which of the following is the most appropriate nursing intervention?

Correct answer: B

Rationale: Based on the signs and symptoms presented in the question, the nurse should suspect peritonitis and should notify the physician. Administering pain medication is not an appropriate intervention. Heat should never be applied to the abdomen of a client with suspected appendicitis. Scheduling surgical time is not within the scope of nursing practice, although the physician probably would perform the surgery earlier than the prescheduled time.

2. After a right hemicolectomy for treatment of colon cancer, a 57-year old client is reluctant to turn while on bed rest. Which action by the nurse would be appropriate?

Correct answer: B

Rationale: Educating the client about the importance of turning can encourage compliance and promote understanding of the necessity to prevent complications such as pressure ulcers and pneumonia.

3. Which of the following nursing measures would be inappropriate when caring for a client with a Cantor tube?

Correct answer: D

Rationale: Intestinal tubes are not irrigated. Injecting air into the tube, applying water-soluble lubricant, and coiling extra tubing are appropriate nursing measures.

4. Which of the following interventions should be included in the medical management of Crohn’s disease?

Correct answer: C

Rationale: Long-term steroid therapy is often used in the management of Crohn's disease to reduce inflammation and suppress the immune response.

5. Sharon has cirrhosis of the liver and develops ascites. What intervention is necessary to decrease the excessive accumulation of serous fluid in her peritoneal cavity?

Correct answer: A

Rationale: Restricting fluids is necessary to decrease the excessive accumulation of serous fluid in the peritoneal cavity for a patient with ascites due to cirrhosis.

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