the nurse would assess the client experiencing an acute episode of cholecystitis for pain that is located in the right
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Nursing Elites

ATI RN

ATI Gastrointestinal System

1. The nurse would assess the client experiencing an acute episode of cholecystitis for pain that is located in the right:

Correct answer: B

Rationale: Pain from cholecystitis is typically located in the right upper quadrant and may radiate to the right scapula and shoulder.

2. A nurse orientee is preparing to insert a nasogastric tube, and a nurse educator is observing the procedure. Which of the following supplies if obtained by the nurse orientee would indicate a need for further education regarding this procedure?

Correct answer: B

Rationale: Water-soluble lubricant is used to lubricate 3 to 4 inches of the tube at the insertion end. An oil lubricant is not used because if the tube accidentally goes into the bronchus, pneumonia can develop. Half-inch tape is used to secure the tube after the correct placement is verified. A 50-mL catheter tip syringe is used to aspirate gastric contents to confirm placement. The client will be asked to take a sip of water through a straw to help with the passage of the tube.

3. The client being treated for esophageal varices has a Sengstaken-Blakemore tube inserted to control the bleeding. The most important assessment is for the nurse to:

Correct answer: C

Rationale: Regularly assessing respiratory status is crucial when a Sengstaken-Blakemore tube is inserted to control bleeding in esophageal varices.

4. 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.

5. You’re caring for Betty with liver cirrhosis. Which of the following assessment findings leads you to suspect hepatic encephalopathy in her?

Correct answer: A

Rationale: Asterixis, a flapping tremor of the hands, is a sign of hepatic encephalopathy.

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