when planning care for a client with ulcerative colitis who is experiencing symptoms which client care activities can the nurse appropriately delegate
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Nursing Elites

ATI RN

ATI Gastrointestinal System Test

1. When planning care for a client with ulcerative colitis who is experiencing symptoms, which client care activities can the nurse appropriately delegate to a unlicensed assistant?

Correct answer: D

Rationale: Delegating tasks such as providing skin care, maintaining intake and output records, and obtaining the client's weight are within the scope of practice for an unlicensed assistant. Assessing bowel sounds and evaluating the response to medications require nursing judgment and should not be delegated.

2. A 40-year-old male client has been hospitalized with peptic ulcer disease. He is being treated with a histamine receptor antagonist (cimetidine), antacids, and diet. The nurse doing discharge planning will teach him that the action of cimetidine is to:

Correct answer: C

Rationale: Cimetidine inhibits the production of hydrochloric acid (HCl), which helps to treat peptic ulcer disease.

3. The hospitalized client with gastroesophageal reflux disease is complaining of chest discomfort that feels like heartburn following a meal. After administering an ordered antacid, the nurse encourages the client to lie in which of the following positions?

Correct answer: C

Rationale: The discomfort of reflux is aggravated by positions that compress the abdomen and the stomach. Lying flat on the back (supine) or on the stomach (prone) after a meal can exacerbate symptoms. Similarly, lying on the right side can worsen reflux. The most appropriate position to alleviate discomfort in a client with gastroesophageal reflux disease is lying on the left side with the head of the bed elevated at a 30-degree angle. This position helps prevent the backflow of stomach contents into the esophagus, providing relief to the client.

4. In a client with diarrhea, which outcome indicates that fluid resuscitation is successful?

Correct answer: C

Rationale: Firm skin turgor indicates adequate hydration, which is a key goal of fluid resuscitation. Formed stools, decreased stool frequency, and relief from perianal burning are important but do not directly indicate successful fluid resuscitation.

5. The nurse is caring for a client following a Billroth II procedure. On review of the postoperative orders, which of the following if prescribed, should the nurse question and verify?

Correct answer: A

Rationale: In a Billroth II procedure the proximal remnant of the stomach is anastomosed to the proximal jejunum. Patency of the nasogastric tube is critical for preventing the retention of gastric secretions. The nurse should never irrigate or reposition the gastric tube after gastric surgery, unless specifically ordered by the physician. In this situation the nurse should clarify the order. Coughing and deep breathing exercises, leg exercises, and early ambulation are appropriate postoperative interventions.

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