the nurse is evaluating the plan of care for a client with peptic ulcer disease with a nursing diagnosis of acute pain the nurse would determine that
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Nursing Elites

ATI RN

ATI Gastrointestinal System

1. The nurse is evaluating the plan of care for a client with peptic ulcer disease with a nursing diagnosis of Acute Pain. The nurse would determine that the client has not met the expected outcomes if the client states

Correct answer: C

Rationale: Expected outcomes for the client with peptic ulcer disease experiencing pain include elimination of irritating foods from the diet, ability to take prescribed medications that will reduce pain, reporting that the pain is relieved or prevented with medication, and an ability to sleep through the night without pain. The client who continues to be awakened by pain requires further modification of medication therapy, which may include adjustment of timing of histamine H2 receptor antagonist or an additional dose of antacid before the time when pain awakens the client.

2. The nurse is irrigating a client's colostomy when she complains of abdominal cramping after receiving about 100 mL of the irrigating solution. What should the nurse's first response be in this situation?

Correct answer: A

Rationale: The abdominal cramping that can occur during colostomy irrigation results from stimulation of the colon by the irrigating solution. The nurse's first response should be to temporarily stop the flow of solution to allow the cramping to subside. Repositioning the client to the right side will not alleviate the cramping. Removing the tube will not decrease the cramping and will necessitate reinsertion of the tube when the irrigation is resumed. Massaging the abdomen gently may be soothing to some clients, but it is not the nurse's first priority action.

3. Before bowel surgery, Lee is to administer enemas until clear. During administration, he complains of intestinal cramps. What do you do next?

Correct answer: B

Rationale: If a patient complains of intestinal cramps during an enema, lowering the height of the enema container can help reduce discomfort.

4. Claire, a 33 y.o. is on your floor with a possible bowel obstruction. Which intervention is priority for her?

Correct answer: B

Rationale: For a patient with a possible bowel obstruction, measuring abdominal girth is a priority to monitor for signs of worsening obstruction or distention.

5. Type A chronic gastritis can be distinguished from type B by its ability to:

Correct answer: A

Rationale: Type A chronic gastritis can cause atrophy of the parietal cells, which is a distinguishing feature from type B.

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