before administering an intermittent tube feeding through a nasogastric tube the nurse assesses for gastric residual the nurse understands that this p
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Nursing Elites

ATI RN

Gastrointestinal System Nursing Exam Questions

1. Before administering an intermittent tube feeding through a nasogastric tube, the nurse assesses for gastric residual. The nurse understands that this procedure is important to

Correct answer: D

Rationale: Evaluating the absorption of the last feeding is important because administration of a tube feeding to a full stomach could result in overdistention, thus predisposing the client to regurgitation and possible aspiration.

2. The client with ascites is scheduled for a paracentesis. The nurse is assisting the physician in performing the procedure. Which of the following positions will the nurse assist the client to assume for this procedure?

Correct answer: D

Rationale: An upright position allows the intestine to float posteriorly and helps prevent intestinal laceration during catheter insertion.

3. A Penrose drain is in place on the first postoperative day following a cholecystectomy. Serosanguineous drainage is noted on the dressing covering the drain. Which nursing intervention is most appropriate?

Correct answer: B

Rationale: Serosanguineous drainage with a small amount of bile is expected from the Penrose drain for the first 24 hours. Drainage then decreases, and the drain is removed usually within 48 hours. The nurse does not need to notify the physician. A sterile dressing covers the site and should be changed to prevent infection and skin excoriation.

4. The nurse is doing pre-op teaching with the client who is about to undergo creation of a Kock pouch. The nurse interprets that the client has the best understanding of the nature of the surgery if the client makes which of the following statements?

Correct answer: A

Rationale: A Kock pouch is a type of continent ileostomy that requires catheterization to empty the internal reservoir. Understanding the need for regular catheterization indicates the client comprehends the procedure.

5. The client with Crohn’s disease has a nursing diagnosis of Acute Pain. The nurse would teach the client to avoid which of the following in managing this problem?

Correct answer: A

Rationale: In managing acute pain associated with Crohn’s disease, the client should avoid lying supine with the legs straight. This position increases muscle tension in the abdomen, potentially aggravating inflamed intestinal tissues as the abdominal muscles are stretched. Massaging the abdomen, using antispasmodic medication, and employing relaxation techniques are beneficial in alleviating pain. Massaging can help relax abdominal muscles, antispasmodic medication can reduce spasms contributing to pain, and relaxation techniques aid in overall pain management. Therefore, choices B, C, and D are appropriate interventions for managing pain in clients with CroCrohn’s disease.

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