to accurately assess for jaundice in a patient with dark skin pigmentation the nurse should examine which body areas
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Nursing Elites

ATI RN

ATI Gastrointestinal System

1. To accurately assess for jaundice in a patient with dark skin pigmentation, the nurse should examine which body areas?

Correct answer: C

Rationale: To accurately assess for jaundice in a patient with dark skin pigmentation, the nurse should examine the hard palate of the mouth. Jaundice is best assessed in the sclera; however, in dark-skinned patients, normal yellow pigmentation may be present in the sclera, making it difficult to detect jaundice. Inspection of the hard palate for a yellow color can confirm the presence of jaundice. Cyanosis is best observed in the nail beds, not indicative of jaundice. While skin on the palm of the hand can indicate jaundice, the back of the hand is not a typical area for assessment. Jaundice can be assessed on the soles of the feet in dark-skinned patients, but it is better visualized in the hard palate for accurate evaluation.

2. Jason, a 22 y.o. accident victim, requires an NG tube for feeding. What should you immediately do after inserting an NG tube for liquid enteral feedings?

Correct answer: A

Rationale: Immediately after inserting an NG tube for enteral feedings, aspirate for gastric secretions to confirm proper placement.

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. A nurse has been caring for a client with a Sengstaken-Blakemore tube. The physician arrives on the nursing unit and deflates the esophageal balloon. The nurse should monitor the client most closely for which of the following?

Correct answer: C

Rationale: A Sengstaken-Blakemore tube is inserted into a client with a diagnosis of cirrhosis and ruptured esophageal varices. The tube has an esophageal and a gastric balloon. The esophageal balloon exerts pressure on the bleeding. The pressure of the esophageal balloon is released at intervals to decrease the risk of trauma to esophageal tissues, including esophageal rupture or necrosis. When the balloon is deflated the client may begin to bleed again from the esophageal varices, noted by vomiting of blood.

5. When teaching an elderly client how to prevent constipation, which of the following instructions should the nurse include?

Correct answer: D

Rationale: To prevent constipation, elderly clients should be encouraged to get regular exercise, which promotes bowel motility.

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