ATI RN
ATI Gastrointestinal System
1. 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.
2. 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.
3. Which of the following interventions should be included in the medical management of Crohn’s disease?
- A. Increasing oral intake of fiber
- B. Administering laxatives
- C. Using long-term steroid therapy
- D. Increasing physical activity
Correct answer: C
Rationale: Long-term steroid therapy is often used in the management of Crohn's disease to reduce inflammation and suppress the immune response.
4. The nurse is performing a colostomy irrigation on a client. During the irrigation, a client begins to complain of abdominal cramps. Which of the following is the most appropriate nursing action?
- A. Notify the physician
- B. Increase the height of the irrigation
- C. Stop the irrigation temporarily.
- D. Medicate with dilaudid and resume the irrigation
Correct answer: C
Rationale: If a client experiences abdominal cramps during a colostomy irrigation, it is appropriate to stop the irrigation temporarily to allow the cramps to subside.
5. 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.
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