which of the following conditions is most likely to directly cause peritonitis
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Nursing Elites

ATI RN

ATI Gastrointestinal System Quizlet

1. Which of the following conditions is most likely to directly cause peritonitis?

Correct answer: C

Rationale: A perforated ulcer is most likely to directly cause peritonitis due to the leakage of gastric contents into the peritoneal cavity.

2. When a client has peptic ulcer disease, the nurse would expect a priority intervention to be:

Correct answer: C

Rationale: Inserting a nasogastric tube is a priority intervention for a client with peptic ulcer disease to decompress the stomach.

3. The nurse develops a plan of care for a client with a T tube. Which one of the following nursing interventions should be included?

Correct answer: A

Rationale: The correct nursing intervention to include in the plan of care for a client with a T tube is to inspect the skin around the T tube daily for irritation. Bile is erosive and can cause skin irritation, so it is crucial to keep the skin clean and dry. T tubes are not routinely irrigated; irrigation is done only with a physician's order. It is unnecessary to maintain the client in a supine position; instead, assist the client into a position of comfort. T tubes are not typically clamped unless ordered by a physician, and if clamped, it is usually done 1 to 2 hours before and after meals.

4. The nurse has inserted a nasogastric tube to the level of the oropharynx and has repositioned the client’s head in a flexed-forward position. The client has been asked to begin swallowing. The nurse starts slowly to advance the nasogastric tube with each swallow. The client begins to cough, gag, and choke. Which nursing action would least likely result in proper tube insertion and promote client relaxation?

Correct answer: A

Rationale: As the nasogastric tube is passed through the oropharynx, the gag reflex is stimulated, which may cause coughing, gagging, or choking. Instead of passing through to the esophagus, the nasogastric tube may coil around itself in the oropharynx, or it may enter the larynx and obstruct the airway, pulling the tube back slightly will remove it from the larynx; advancing the tube might position it in the trachea. Swallowing closes the epiglottis over the trachea and helps move the tube into the esophagus. Slow breathing helps the client relax to reduce the gag response. The nurse should check the back of the client’s throat to note if the tube has coiled. The tube may be advanced after the client relaxes.

5. If a gastric acid perforates, which of the following actions should not be included in the immediate management of the client?

Correct answer: B

Rationale: Antacid administration should not be included in the immediate management of a gastric perforation.

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