which of the following measures should the nurse focus on for the client with esophageal varices
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Nursing Elites

ATI RN

ATI Gastrointestinal System

1. 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.

2. When teaching a community group about measures to prevent colon cancer, which instruction should the nurse include?

Correct answer: A

Rationale: Limiting fat intake is a recommended measure to reduce the risk of colon cancer. Including fiber, undergoing annual rectal examinations, and sigmoidoscopy are also important, but limiting fat intake is directly related to reducing cancer risk.

3. The physician orders a Salem sump tube for gastrointestinal intubation. The nurse prepares for the insertion and obtains which of the following items from the supply room?

Correct answer: B

Rationale: A tube with a large lumen and an air vent is a Salem sump tube. A tube with a single lumen is called a Levin’s tube. A Sengstaken-Blakemore tube is used to control bleeding in the esophagus. A Dobbhoff weighted tube is used for feedings.

4. In a client with Crohn’s disease, which of the following symptoms should not be a direct result from antibiotic therapy?

Correct answer: C

Rationale: Decrease in body weight is not a direct result of antibiotic therapy but may occur due to the underlying disease process.

5. You’re patient, post-op drainage of a pelvic abscess secondary to diverticulitis, begins to cough violently after drinking water. His wound has ruptured and a small segment of the bowel is protruding. What’s your priority?

Correct answer: D

Rationale: For a patient with a ruptured wound and protruding bowel, call the doctor while remaining with the patient, flex the patient’s knees, and cover the wound with sterile towels soaked in sterile saline solution.

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