a nurse is preforming a gastric lavage for a client who has upper gastrointestinal bleeding which of the following action should the nurse take
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Nursing Elites

ATI RN

ATI Fundamentals Proctored Exam 2023

1. A healthcare provider is performing a gastric lavage for a client who has upper gastrointestinal bleeding. Which of the following actions should the healthcare provider take?

Correct answer: B

Rationale: During a gastric lavage procedure for upper gastrointestinal bleeding, inserting a large-bore NG tube is essential to effectively remove gastric contents and blood. This tube allows for efficient irrigation and suction, aiding in the removal of harmful substances from the stomach. Instilling a large volume of solution or using a cold irrigation solution can lead to complications such as fluid overload or hypothermia. Instructing the client to lie on their right side is not directly related to the gastric lavage procedure.

2. After a walk-in client enters the clinic with a chief complaint of abdominal pain and diarrhea, the nurse takes the client’s vital signs. What phase of the nursing process is being implemented by the nurse?

Correct answer: A

Rationale: In this scenario, the nurse is performing the assessment phase of the nursing process. Assessment involves collecting data, which includes obtaining vital signs, to identify the client's health status and needs. This step is crucial for the nurse to gather information that will guide further decision-making in the nursing process. Choice B, 'Diagnosis,' would involve analyzing the collected data to identify the client's health problems. Choice C, 'Planning,' would be developing a plan of care based on the assessment findings. Choice D, 'Implementation,' is the phase where the nurse carries out the plan of care developed during the planning phase.

3. What is a nurse's role in health promotion?

Correct answer: B

Rationale: A nurse plays a crucial role in health promotion by educating clients to be effective health consumers. This involves empowering individuals to make informed decisions about their health, access appropriate healthcare services, and engage in healthy behaviors to prevent illness and promote well-being. The other choices are not entirely accurate in describing the primary role of a nurse in health promotion. While nurses may conduct health risk appraisals and implement worksite wellness programs as part of their responsibilities, their central focus is on educating and empowering individuals to take control of their health.

4. Which of the following conditions in the client's history is a contraindication to the use of oral contraceptives?

Correct answer: B

Rationale: Thrombophlebitis, which is inflammation of a vein with the formation of a clot, is a contraindication to the use of oral contraceptives due to an increased risk of thromboembolism. Clients with a history of thrombophlebitis or thromboembolic disorders should avoid oral contraceptives to prevent further complications like deep vein thrombosis or pulmonary embolism.

5. Which of the following is the correct abbreviation for drops?

Correct answer: A

Rationale: The correct abbreviation for drops in medical terminology is 'Gtt.' It is derived from the Latin word 'guttae,' meaning drops. The abbreviation 'Gtts.' (Choice B) is incorrect as it adds an unnecessary 's.' Choices C and D, 'Dp.' and 'Dr.,' are not standard abbreviations for drops in medical contexts, making them incorrect.

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