you are developing a careplan on sally a 67 yo patient with hepatic encephalopathy which of the following do you include
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Nursing Elites

ATI RN

ATI Gastrointestinal System Test

1. You are developing a careplan on Sally, a 67 y.o. patient with hepatic encephalopathy. Which of the following do you include?

Correct answer: A

Rationale: Administering a lactulose enema as ordered helps reduce ammonia levels in patients with hepatic encephalopathy.

2. The nurse is irrigating a client's colostomy when she complains of abdominal cramping after receiving about 100 mL of the irrigating solution. What should the nurse's first response be in this situation?

Correct answer: A

Rationale: The abdominal cramping that can occur during colostomy irrigation results from stimulation of the colon by the irrigating solution. The nurse's first response should be to temporarily stop the flow of solution to allow the cramping to subside. Repositioning the client to the right side will not alleviate the cramping. Removing the tube will not decrease the cramping and will necessitate reinsertion of the tube when the irrigation is resumed. Massaging the abdomen gently may be soothing to some clients, but it is not the nurse's first priority action.

3. A nurse is caring for a client diagnose with pancreatitis. The nurse anticipates that the client would not experience an elevation of which of the following enzymes?

Correct answer: B

Rationale: Lactase is produced in the small intestine and aids in splitting neutral fats into glycerol and fatty acids. Lipase, amylase, and trypsin are produced in the pancreas and aid in the digestion of fats, starches, and proteins, respectively.

4. 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.

5. A client returns from surgery with a sigmoid colostomy. An ostomy appliance is attached. The priority nursing diagnosis for daily observation and care is:

Correct answer: B

Rationale: Impaired skin integrity would be the priority nursing diagnosis for daily care of the colostomy because the effluent from the colostomy can be irritating to the skin. Diarrhea isn't a concern at this point. The client will be allowed nothing by mouth until peristalsis returns. The client should get out of bed on the first postoperative day, so mobility shouldn't be a problem.

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