the nurse is caring for a client with a diagnosis of cirrhosis and is monitoring the client for signs of portal hypertension which initial sign if not
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Nursing Elites

ATI RN

ATI Gastrointestinal System

1. The nurse is caring for a client with a diagnosis of cirrhosis and is monitoring the client for signs of portal hypertension. Which initial sign, if noted in the client, indicates the presence of portal hypertension?

Correct answer: D

Rationale: Clinical signs and symptoms or portal hypertension are identical to those of heart failure and include jugular vein distention, lung crackles, and decreased perfusion to all organs. Initially, the client may have hypertension, flushed skin, and a bounding pulse.

2. The nurse is preparing a discharge teaching plan for the client who had an umbilical hernia repair. Which of the following would the nurse include in the plan?

Correct answer: C

Rationale: To prevent strain on the surgical site and avoid disruption of tissue integrity, the client should avoid coughing after an umbilical hernia repair.

3. 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.

4. You’re preparing a teaching plan for a 27 y.o. named Jeff who underwent surgery to close a temporary ileostomy. Which nutritional guideline do you include in this plan?

Correct answer: B

Rationale: After ileostomy closure surgery, it is recommended to eat six small meals a day to aid digestion and absorption.

5. Kevin has a history of peptic ulcer disease and vomits coffee-ground emesis. What does this indicate?

Correct answer: C

Rationale: Coffee-ground emesis is a sign of upper gastrointestinal bleeding that occurred approximately 2 hours earlier. It results from the breakdown of blood in the stomach due to digestive enzymes, giving it a coffee-ground appearance. Choice A is incorrect because coffee-ground emesis indicates older, partially digested blood, not fresh active bleeding. Choice B is incorrect as gastric lavage is not indicated for coffee-ground emesis. Choice D is incorrect because a transfusion of packed RBCs is not the immediate management for this presentation.

Similar Questions

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The client with Crohn’s disease has a nursing diagnosis of Acute Pain. The nurse would teach the client to avoid which of the following in managing this problem?
The client with a new colostomy is concerned about the odor from stool from the ostomy drainage bag. The nurse teaches the client to include which of the following foods in the diet to reduce odor?
Which of the following diagnostic tests may be performed to determine if a client has gastric cancer?
The client with a duodenal ulcer may exhibit which of the following findings on assessment?

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