ATI RN
ATI Gastrointestinal System
1. 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.
2. A nurse is inserting a nasogastric tube in an adult client. During the procedure, the client begins to cough and has difficulty breathing. Which of the following is the most appropriate nursing action?
- A. Remove the tube and reinsert when the respiratory distress subsides.
- B. Pull back on the tube and wait until the respiratory distress subsides.
- C. Quickly insert the tube.
- D. Notify the physician immediately.
Correct answer: B
Rationale: During the insertion of a nasogastric tube, if the client experiences difficulty breathing or any respiratory distress, withdraw the tube slightly, stop the tube advancement, and wait until the distress subsides. Options 1 and 4 are unnecessary. Quickly inserting the tube is not an appropriate action because, in this situation, it may be likely that the tube has entered the bronchus.
3. Claire, a 33 y.o. is on your floor with a possible bowel obstruction. Which intervention is priority for her?
- A. Obtain daily weights.
- B. Measure abdominal girth.
- C. Keep strict intake and output.
- D. Encourage her to increase fluids.
Correct answer: B
Rationale: For a patient with a possible bowel obstruction, measuring abdominal girth is a priority to monitor for signs of worsening obstruction or distention.
4. Which goal of the client’s care should take priority during the first days of hospitalization for an exacerbation of ulcerative colitis?
- A. Promoting self-care and independence
- B. Managing diarrhea
- C. Maintaining adequate nutrition
- D. Promoting rest and comfort
Correct answer: B
Rationale: Managing diarrhea should take priority during the first days of hospitalization for an exacerbation of ulcerative colitis.
5. Medical management of the client with diverticulitis should include which of the following treatments?
- A. Reduced fluid intake
- B. Increased fiber in diet
- C. Administration of antibiotics
- D. Exercises to increase intra-abdominal pressure
Correct answer: C
Rationale: Medical management of diverticulitis typically includes the administration of antibiotics to treat infection and inflammation.
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