ATI RN
ATI Gastrointestinal System
1. Mucosal barrier fortifiers are used in peptic ulcer disease management for which of the following indications?
- A. To inhibit mucus production
- B. To neutralize acid production
- C. To stimulate mucus production
- D. To stimulate hydrogen ion diffusion back into the mucosa
Correct answer: C
Rationale: Mucosal barrier fortifiers stimulate mucus production, which helps protect the lining of the stomach and manage peptic ulcer disease.
2. A nurse orientee is preparing to insert a nasogastric tube, and a nurse educator is observing the procedure. Which of the following supplies if obtained by the nurse orientee would indicate a need for further education regarding this procedure?
- A. Half-inch or one-inch tape
- B. Oil-soluble lubricant
- C. A glass of tap water with a straw
- D. A 50-mL catheter tip syringe
Correct answer: B
Rationale: Water-soluble lubricant is used to lubricate 3 to 4 inches of the tube at the insertion end. An oil lubricant is not used because if the tube accidentally goes into the bronchus, pneumonia can develop. Half-inch tape is used to secure the tube after the correct placement is verified. A 50-mL catheter tip syringe is used to aspirate gastric contents to confirm placement. The client will be asked to take a sip of water through a straw to help with the passage of the tube.
3. The nurse is caring for a client on the first postoperative day following a surgical repair of an abdominal aortic aneurysm. Which nursing diagnosis is the most important for this client?
- A. Risk for infection
- B. Deficient knowledge
- C. Ineffective peripheral tissue perfusion
- D. Activity intolerance
Correct answer: C
Rationale: Peripheral tissue perfusion is a major concern in the postoperative period following an abdominal aneurysm repair. Peripheral pulses should be checked frequently during the first 24 hours. A weak or absent pulse may be a sign of embolization or graft closure, especially if accompanied by a pale, cold, mottled extremity; the nurse should immediately report this to the surgeon. Risk for infection, deficient knowledge, and activity intolerance are all important nursing diagnoses in the postoperative period, but peripheral tissue perfusion is the most immediate concern.
4. A client with a peptic ulcer is scheduled for a vagotomy. The client asks the nurse about the purpose of this procedure. The nurse tells the client that the procedure:
- A. Decreases food absorption in the stomach
- B. Heals the gastric mucosa
- C. Halts stress reactions
- D. Reduces the stimulus to acid secretions
Correct answer: D
Rationale: A vagotomy reduces the stimulus to acid secretions by cutting the vagus nerve, which innervates the stomach.
5. Which of the following factors should be the main focus of nursing management for a client hospitalized for cholecystitis?
- A. Administration of antibiotics
- B. Assessment for complications
- C. Preparation for lithotripsy
- D. Preparation for surgery
Correct answer: B
Rationale: Assessment for complications should be the main focus of nursing management for a client hospitalized for cholecystitis.
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