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
Logo

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. In a client with diarrhea, which outcome indicates that fluid resuscitation is successful?

Correct answer: C

Rationale: Firm skin turgor indicates adequate hydration, which is a key goal of fluid resuscitation. Formed stools, decreased stool frequency, and relief from perianal burning are important but do not directly indicate successful fluid resuscitation.

3. The nurse evaluates the client’s stoma during the initial post-op period. Which of the following observations should be reported immediately to the physician?

Correct answer: B

Rationale: A dark red to purple stoma may indicate compromised blood flow or ischemia, which requires immediate medical attention. This color change could be a sign of inadequate blood supply to the stoma tissue, leading to tissue damage or necrosis. Reporting this observation promptly is crucial to prevent further complications. Choices A, C, and D are not indicative of immediate medical concern. A slightly edematous stoma, oozing a small amount of blood, or not expelling stool may not be uncommon findings during the initial post-op period and can be managed without urgent intervention.

4. Mucosal barrier fortifiers are used in peptic ulcer disease management for which of the following indications?

Correct answer: C

Rationale: Mucosal barrier fortifiers stimulate mucus production, which helps protect the lining of the stomach and manage peptic ulcer disease.

5. Which of the following complications is thought to be the most common cause of appendicitis?

Correct answer: A

Rationale: A fecalith is a hardened stool that can block the appendix, leading to inflammation and infection, which is the most common cause of appendicitis.

Similar Questions

The client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate post-op period for which of the following most frequent complications of this type of surgery?
After an abdominal resection for colon cancer, Madeline returns to her room with a Jackson-Pratt drain in place. The purpose of the drain is to:
A client has a nasogastric tube inserted at the time of abdominal perineal resection with permanent colostomy. This tube will most likely be removed when the client demonstrates:
The nurse has given instructions to the client with an ileostomy about foods to eat to thicken the stool. The nurse determines that the client needs further instructions if the client stated to eat which of the following foods to make the stools less watery?
Which of the following aspects is the priority focus of nursing management for a client with peritonitis?

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses