a nurse is developing a plan of care for a client who will be returning to a nursing unit following a percutaneous transhephatic cholangiogram the nur
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Nursing Elites

ATI RN

Gastrointestinal System Nursing Exam Questions

1. A nurse is developing a plan of care for a client who will be returning to a nursing unit following a percutaneous transhephatic cholangiogram. The nurse includes which intervention in the postprocedure plan of care?

Correct answer: A

Rationale: Following this procedure, the nurse monitors the client’s vital signs closely for indications of hemorrhage and observes the needle insertion site for bleeding and bile leakage. A sandbag is placed over the insertion site to prevent bleeding. The client is maintained on bedrest, and oral intake is avoided in the immediate postprocedure period in case surgery is necessary to control hemorrhage of bile extravasation.

2. When obtaining a nursing history on a client with a suspected gastric ulcer, which signs and symptoms would the nurse expect to see? Select ONE that does not apply.

Correct answer: B

Rationale: Signs and symptoms of a gastric ulcer include epigastric pain at night, vomiting, and weight loss. Relief of epigastric pain after eating is not typically associated with gastric ulcers.

3. Which of the following areas is the most common site of fistulas in clients with Crohn’s disease?

Correct answer: A

Rationale: The anorectal area is the most common site of fistulas in clients with Crohn's disease.

4. A nurse is performing an assessment on a client with a suspected diagnosis of acute pancreatitis. The nurse assesses the client, knowing that which of the following is a hallmark sign of this disorder?

Correct answer: B

Rationale: A hallmark sign of acute pancreatitis is severe abdominal pain that is not relieved by vomiting. Nausea and vomiting are common presenting symptoms, with vomitus typically consisting of gastric and duodenal contents. Hypothermia is not a hallmark sign of acute pancreatitis. Fever, typically less than 38 degrees centigrade, is more common. Epigastric pain radiating to the neck area is not a characteristic sign of acute pancreatitis. Therefore, choice B is the correct answer.

5. A client with a peptic ulcer reports epigastric pain that frequently awakens her at night, a feeling of fullness in the abdomen, and a feeling of anxiety about her health. Based on this information, which nursing diagnosis would be most appropriate?

Correct answer: B

Rationale: Disturbed Sleep Pattern related to epigastric pain is appropriate because the client reports pain that frequently awakens her at night.

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