ATI RN
ATI Gastrointestinal System Test
1. The nurse evaluates the client’s stoma during the initial post-op period. Which of the following observations should be reported immediately to the physician?
- A. The stoma is slightly edematous
- B. The stoma is dark red to purple
- C. The stoma oozes a small amount of blood
- D. The stoma does not expel stool
Correct answer: B
Rationale: A dark red to purple stoma may indicate compromised blood flow or ischemia, which requires immediate medical attention. This color change could be a sign of inadequate blood supply to the stoma tissue, leading to tissue damage or necrosis. Reporting this observation promptly is crucial to prevent further complications. Choices A, C, and D are not indicative of immediate medical concern. A slightly edematous stoma, oozing a small amount of blood, or not expelling stool may not be uncommon findings during the initial post-op period and can be managed without urgent intervention.
2. You’re caring for Jane, a 57 y.o. patient with liver cirrhosis who develops ascites and requires paracentesis. Before her paracentesis, you instruct her to:
- A. Empty her bladder.
- B. Lie supine in bed.
- C. Remain NPO for 4 hours.
- D. Clean her bowels with an enema.
Correct answer: A
Rationale: Before paracentesis, instruct the patient to empty her bladder to avoid bladder injury during the procedure.
3. 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?
- A. Pruritus
- B. Dyspnea
- C. Jaundice
- D. Peripheral Neuropathy
Correct answer: B
Rationale: Dyspnea relief indicates that the paracentesis was effective in reducing ascites.
4. Which of the following measures should the nurse focus on for the client with esophageal varices?
- A. Recognizing hemorrhage
- B. Controlling blood pressure
- C. Encouraging nutritional intake
- D. Teaching the client about 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. The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750ml of green-brown drainage. Which nursing intervention is most appropriate?
- A. Notify the physician
- B. Document the findings
- C. Irrigate the T-tube
- D. Clamp the T-tube
Correct answer: B
Rationale: Documenting the findings is the most appropriate action as 750ml of green-brown drainage is expected after a cholecystectomy.
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