a home care nurse is visiting a client with a diagnosis of pernicious anemia that developed as a result of gastric surgery the nurse instructs the cli
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Nursing Elites

ATI RN

Gastrointestinal System Nursing Exam Questions

1. A home care nurse is visiting a client with a diagnosis of pernicious anemia that developed as a result of gastric surgery. The nurse instructs the client that because the stomach lining produces a decreased amount of intrinsic factor in this disorder, the client will need

Correct answer: A

Rationale: A lack of the intrinsic factor needed to absorb vitamin B12 occurs in pernicious anemia. Vitamin B12 is needed for the maturation of red blood cells. Vitamin B6 is not necessarily needed for pernicious anemia and can be taken orally. An antibiotic and antacids may be prescribed for certain types of gastric ulcers.

2. You’re caring for Beth who underwent a Billroth II procedure (surgical removal of the pylorus and duodenum) for treatment of a peptic ulcer. Which findings suggest that the patient is developing dumping syndrome, a complication associated with this procedure?

Correct answer: C

Rationale: Dizziness and sweating are common signs of dumping syndrome, a complication of the Billroth II procedure.

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. Which of the following measures should the nurse focus on for the client with esophageal varices?

Correct answer: A

Rationale: The primary focus for a client with esophageal varices is recognizing hemorrhage because these varices can rupture and cause significant bleeding.

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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