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. 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. You’re caring for Lewis, a 67 y.o. patient with liver cirrhosis who develops ascites and requires paracentesis. Relief of which symptom indicated that the paracentesis was effective?

Correct answer: B

Rationale: Dyspnea relief indicates that the paracentesis was effective in reducing ascites.

4. George has a T tube in place after gallbladder surgery. Before discharge, what information or instructions should be given regarding the T tube drainage?

Correct answer: B

Rationale: Before discharge, inform the patient that the drainage will decrease daily until the bile duct heals.

5. The client with ascites is scheduled for a paracentesis. The nurse is assisting the physician in performing the procedure. Which of the following positions will the nurse assist the client to assume for this procedure?

Correct answer: D

Rationale: An upright position allows the intestine to float posteriorly and helps prevent intestinal laceration during catheter insertion.

Similar Questions

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A client has just had surgery for colon cancer. Which of the following disorders might the client develop?
When planning care for a client with ulcerative colitis who is experiencing symptoms, which client care activities can the nurse appropriately delegate to a unlicensed assistant?
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