ATI RN
ATI Gastrointestinal System
1. The nurse is caring for a client with cirrhosis. Which manifestations indicate deficient vitamin K absorption caused by this liver disease?
- A. Dyspnea and fatigue
- B. Ascites and orthopnea
- C. Purpura and petechiae
- D. Gynecomastia and testicular atrophy
Correct answer: C
Rationale: A liver disorder, such as cirrhosis, can disrupt the liver's normal use of vitamin K to produce prothrombin (a clotting factor). Because of this, the nurse should monitor the client for signs of bleeding, including purpura and petechiae. Dyspnea and fatigue suggest anemia. Ascites and orthopnea are unrelated to vitamin K absorption. Gynecomastia and testicular atrophy result from decreased estrogen metabolism by the diseased liver.
2. A client with a peptic ulcer reports epigastric pain that frequently awakens her at night, a feeling of fullness in the abdomen, and a feeling of anxiety about her health. Based on this information, which nursing diagnosis would be most appropriate?
- A. Imbalanced Nutrition: Less than Body Requirements related to anorexia.
- B. Disturbed Sleep Pattern related to epigastric pain
- C. Ineffective Coping related to exacerbation of duodenal ulcer
- D. Activity Intolerance related to abdominal pain
Correct answer: B
Rationale: Disturbed Sleep Pattern related to epigastric pain is appropriate because the client reports pain that frequently awakens her at night.
3. A client is admitted to the hospital with acute viral hepatitis. Which of the following signs or symptoms would the nurse expect to note based on this diagnosis?
- A. Spider angiomas
- B. Fatigue
- C. Pale urine
- D. Weight gain
Correct answer: B
Rationale: Common signs of acute viral hepatitis include weight loss, dark urine, and fatigue. The client is anorexic, possibly from a toxin produced by the diseased liver, and finds food distasteful. The urine darkens because of excess bilirubin being excreted by the kidneys. Fatigue occurs during all phases of hepatitis.
4. 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?
- A. A tube with a single lumen that connects to suction
- B. A tube with a large lumen and an air vent
- C. A Sengstaken-Blakemore tube
- D. A Dobbhoff weighted tube
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.
5. A client has been taking aluminum hydroxide 30 mL six times per day at home to treat his peptic ulcer. He tells the nurse that he has been unable to have a bowel movement for 3 days. Based on this information, the nurse would determine that which of the following is the most likely cause of the client’s constipation?
- A. The client has not been including enough fiber in his diet
- B. The client needs to increase his daily exercise
- C. The client is experiencing a side effect of the aluminum hydroxide.
- D. The client has developed a gastrointestinal obstruction.
Correct answer: C
Rationale: The client is experiencing a common side effect of aluminum hydroxide, which is constipation.
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