youre caring for lewis a 67 yo patient with liver cirrhosis who develops ascites and requires paracentesis relief of which symptom indicated that the
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Nursing Elites

ATI RN

ATI Gastrointestinal System Test

1. 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.

2. The nurse is caring for a client following a Billroth II procedure. On review of the post-operative orders, which of the following, if prescribed, would the nurse question and verify?

Correct answer: A

Rationale: Irrigating the nasogastric tube is typically not recommended after a Billroth II procedure unless specifically ordered by a physician due to the risk of disrupting the surgical site.

3. Which nursing measure would be most effective in helping the client cough and deep breathe after a cholecystectomy?

Correct answer: C

Rationale: After a cholecystectomy, teaching the client to use a folded blanket or pillow to splint the incision will be most effective in helping the client cough and deep breathe. This technique provides support and reduces pain during coughing and deep breathing, promoting better lung expansion. Having the client take rapid, shallow breaths would not be effective in decreasing pain; instead, deep breathing is encouraged to prevent complications like atelectasis. Lying on the left side would limit lung expansion; therefore, the client should be positioned in semi-Fowler's or Fowler's position to maximize lung expansion. Withholding pain medication can lead to discomfort and reluctance to cough and deep breathe, hindering recovery.

4. The student nurse is participating in colorectal cancer-screening program. Which patient has the fewest risk factors for colon cancer?

Correct answer: C

Rationale: Herman, a 60 y.o. who follows a low-fat, high-fiber diet, has the fewest risk factors for colon cancer.

5. A nurse is caring for a client who has just returned from the operating room following the creation of a colostomy. The nurse is assessing the drainage in the pouch attached to the site where the colostomy was formed and notes serosanguineous drainage. Which nursing action is most appropriate based on this assessment?

Correct answer: B

Rationale: During the first 24 to 72 hours following surgery, mucus and serosanguineous drainage are expected from the stoma. Documenting the amount and characteristics of the drainage is appropriate. The nurse does not need to notify the physician because this is an expected finding. Applying ice or pressure to the site is not necessary.

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