the client with cirrhosis has ascites and excess fluid volume which measure will the nurse include in the plan of care for this client
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Nursing Elites

ATI RN

Gastrointestinal System Nursing Exam Questions

1. The client with cirrhosis has ascites and excess fluid volume. Which measure will the nurse include in the plan of care for this client?

Correct answer: B

Rationale: Excess fluid volume, related to the accumulation of fluid in the peritoneal and dependent areas of the body, can occur in the client with cirrhosis. Fluids should be restricted, including fluids given in medications and meals. Sodium restriction also aids in reducing fluid volume excess.

2. 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.

3. When a client has peptic ulcer disease, the nurse would expect a priority intervention to be:

Correct answer: C

Rationale: Inserting a nasogastric tube is a priority intervention for a client with peptic ulcer disease to decompress the stomach.

4. A client is providing instructions to a client who is scheduled for an oral cholecystogram. The nurse tells the client to

Correct answer: C

Rationale: For an oral cholecystogram, the client should eat a fat-free meal the evening before the procedure and avoid oral intake except for water on the day of the procedure. During the test, the client may be given a high-fat meal or drink to stimulate gallbladder emptying. Choice A is incorrect because the client should have a fat-free meal, not a high-fat meal. Choice B is incorrect as strict NPO status is not required. Choice D is incorrect as a high-fat meal is not recommended for breakfast on the day of the procedure.

5. Which of the following therapies is not included in the medical management of a client with peritonitis?

Correct answer: D

Rationale: A regular diet is not included in the medical management of peritonitis, which requires bowel rest and IV fluids.

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