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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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. To prevent gastroesophageal reflux in a client with hiatal hernia, the nurse should provide which discharge instructions?

Correct answer: B

Rationale: To prevent reflux of stomach acid into the esophagus, the nurse should advise the client to avoid foods and beverages that tend to increase stomach acid, such as coffee and alcohol. The nurse also should teach the client to avoid lying down after meals, which can aggravate reflux, and to take antacids after eating. The client doesn't need to limit fluids with meals as long as the fluids aren't gastric irritants.

3. The nurse is caring for a client with chronic gastritis. The nurse monitors the client, knowing that this client is at risk for which of the following vitamin deficiencies?

Correct answer: B

Rationale: Clients with chronic gastritis are at risk for Vitamin B12 deficiency due to impaired absorption.

4. The nurse is monitoring a client for the early signs of dumping syndrome. Which symptom indicates this occurrence?

Correct answer: C

Rationale: Sweating and pallor are early signs of dumping syndrome, a condition where food moves too quickly from the stomach to the small intestine.

5. A nurse is assigned to a 40-year-old client who has a diagnosis of chronic pancreatitis. The nurse reviews the laboratory result, anticipating a laboratory report that indicates a serum amylase level of

Correct answer: C

Rationale: The normal serum amylase level is 25 to 151 IU/L. With chronic cases of pancreatitis, the rise in serum amylase levels usually does not exceed three times the normal value. In acute pancreatitis, the value may exceed five times the normal value. Options 1 and 2 are within normal limits. Option 3 is an extremely elevated level seen in acute pancreatitis.

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