your patient with peritonitis is npo and complaining of thirst what is your priority
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Nursing Elites

ATI RN

Gastrointestinal System ATI

1. Your patient with peritonitis is NPO and complaining of thirst. What is your priority?

Correct answer: C

Rationale: The correct answer is C: Provide frequent mouth care. In a patient with peritonitis who is NPO and thirsty, the priority is to maintain oral hygiene and provide comfort by moistening the mouth with frequent mouth care. This helps alleviate the sensation of thirst and maintains oral health. Increasing the IV infusion rate (choice A) may not address the patient's discomfort directly related to thirst. Using diversion activities (choice B) is not as critical as addressing the patient's immediate need for oral care. Giving ice chips every 15 minutes (choice D) is not recommended for a patient with peritonitis who is NPO, as it can lead to complications or worsen the condition.

2. The client who has undergone creation of a colostomy has a nursing diagnosis of Disturbed body image. The nurse would evaluate that the client is making the most significant progress toward identified goals if the client:

Correct answer: D

Rationale: The correct answer is D: Practices cutting the ostomy appliance. This choice indicates that the client is actively involved in self-care and adapting to the colostomy. By practicing cutting the ostomy appliance, the client is demonstrating independence and self-management skills, showing significant progress towards overcoming the disturbed body image. Choices A, B, and C do not involve active participation in self-care tasks related to the colostomy, which are essential for the client's adaptation and acceptance.

3. Rob is a 46 y.o. admitted to the hospital with a suspected diagnosis of Hepatitis B. He’s jaundiced and reports weakness. Which intervention will you include in his care?

Correct answer: D

Rationale: For a patient with hepatitis B who is jaundiced and reports weakness, providing rest periods after small, frequent meals is important.

4. The client has been admitted with a diagnosis of acute pancreatitis. The nurse would assess this client for pain that is:

Correct answer: A

Rationale: Acute pancreatitis typically presents with severe, unrelenting pain in the epigastric area that radiates to the back. This pain is due to inflammation and autodigestion of the pancreas.

5. The nurse is assessing for stoma prolapse in a client with a colostomy. The nurse would observe which of the following if stoma prolapse occurred?

Correct answer: D

Rationale: A protruding stoma is indicative of stoma prolapse, which occurs when the bowel protrudes excessively through the stoma.

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