while caring for a client with peptic ulcer disease the client reports that he has been nauseated most of the day and is now feeling lightheaded and d
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Nursing Elites

ATI RN

ATI Gastrointestinal System

1. While caring for a client with peptic ulcer disease, the client reports that he has been nauseated most of the day and is now feeling lightheaded and dizzy. Based upon these findings, which nursing actions would be most appropriate for the nurse to take? Select all that apply.

Correct answer: 2, 3

Rationale: Monitoring the client's vital signs and notifying the physician of the client's symptoms are crucial actions based on the reported symptoms.

2. The nurse evaluates the client’s stoma during the initial post-op period. Which of the following observations should be reported immediately to the physician?

Correct answer: B

Rationale: A dark red to purple stoma may indicate compromised blood flow or ischemia, which requires immediate medical attention. This color change could be a sign of inadequate blood supply to the stoma tissue, leading to tissue damage or necrosis. Reporting this observation promptly is crucial to prevent further complications. Choices A, C, and D are not indicative of immediate medical concern. A slightly edematous stoma, oozing a small amount of blood, or not expelling stool may not be uncommon findings during the initial post-op period and can be managed without urgent intervention.

3. The student nurse is preparing a teaching care plan to help improve nutrition in a patient with achalasia. You include which of the following:

Correct answer: C

Rationale: Eating meals while sitting upright helps improve swallowing and prevent complications in patients with achalasia.

4. 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.

5. Brenda, a 36 y.o. patient is on your floor with acute pancreatitis. Treatment for her includes:

Correct answer: C

Rationale: Treatment for acute pancreatitis includes nutritional support with TPN.

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