ATI RN
ATI Gastrointestinal System
1. 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?
- A. Imbalanced Nutrition: Less than Body Requirements related to anorexia.
- B. Disturbed Sleep Pattern related to epigastric pain
- C. Ineffective Coping related to exacerbation of duodenal ulcer
- D. Activity Intolerance related to abdominal pain
Correct answer: B
Rationale: Disturbed Sleep Pattern related to epigastric pain is appropriate because the client reports pain that frequently awakens her at night.
2. Elmer is scheduled for a proctoscopy and has an I.V. The doctor wrote an order for 5mg of I.V. diazepam(Valium). Which order is correct regarding diazepam?
- A. Give diazepam in the I.V. port closest to the vein.
- B. Mix diazepam with 50 ml of dextrose 5% in water and give over 15 minutes.
- C. Give diazepam rapidly I.V. to prevent the bloodstream from diluting the drug mixture.
- D. Question the order because I.V. administration of diazepam is contraindicated.
Correct answer: A
Rationale: The correct method for administering I.V. diazepam is to give it in the I.V. port closest to the vein.
3. A client with liver dysfunction is having difficulty with protein metabolism. The nurse anticipates that the results of which of the following serum laboratory studies will be elevated?
- A. Lactic acid
- B. Ammonia
- C. Albumin
- D. Lactase
Correct answer: B
Rationale: During deamination of proteins, the liver splits the amino group from the carbon-containing compound, which results in the formation of ammonia and a carbon residue. The liver then converts the toxic ammonia substance into urea, which can be excreted by the kidneys. Clients with liver dysfunction may have high serum ammonia levels as a result.
4. Which of the following nursing measures would be inappropriate when caring for a client with a Cantor tube?
- A. Injecting 10 mL of air into the tube to facilitate drainage.
- B. Applying a water-soluble lubricant to the client's nares.
- C. Coiling extra tubing on the client's bed.
- D. Irrigating the tube with 50 mL of normal saline solution.
Correct answer: D
Rationale: Intestinal tubes are not irrigated. Injecting air into the tube, applying water-soluble lubricant, and coiling extra tubing are appropriate nursing measures.
5. The client with a colostomy has an order for irrigation of the colostomy. The nurse used which solution for irrigation?
- A. Distilled water
- B. Tap water
- C. Sterile water
- D. Lactated Ringer’s
Correct answer: B
Rationale: Tap water at body temperature is generally used for colostomy irrigation unless the local water supply is not safe for drinking, in which case bottled water can be used.
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