ATI RN
Gastrointestinal System ATI
1. Your patient with peritonitis is NPO and complaining of thirst. What is your priority?
- A. Increase the I.V. infusion rate.
- B. Use diversion activities.
- C. Provide frequent mouth care.
- D. Give ice chips every 15 minutes.
Correct answer: C
Rationale: The correct answer is C: Provide frequent mouth care. In a patient with peritonitis who is NPO and thirsty, the priority is to maintain oral hygiene and provide comfort by moistening the mouth with frequent mouth care. This helps alleviate the sensation of thirst and maintains oral health. Increasing the IV infusion rate (choice A) may not address the patient's discomfort directly related to thirst. Using diversion activities (choice B) is not as critical as addressing the patient's immediate need for oral care. Giving ice chips every 15 minutes (choice D) is not recommended for a patient with peritonitis who is NPO, as it can lead to complications or worsen the condition.
2. Which of the following complications is thought to be the most common cause of appendicitis?
- A. A fecalith
- B. Bowel kinking
- C. Internal bowel occlusion
- D. Abdominal bowel swelling
Correct answer: A
Rationale: A fecalith is a hardened stool that can block the appendix, leading to inflammation and infection, which is the most common cause of appendicitis.
3. 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.
4. When teaching a community group about measures to prevent colon cancer, which instruction should the nurse include?
- A. Limit fat intake to 20% to 25% of your total daily calories.
- B. Include 15 to 20 grams of fiber into your daily diet.
- C. Get an annual rectal examination after age 35.
- D. Undergo sigmoidoscopy annually after age 50.
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.
5. 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.
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