ATI RN
ATI Gastrointestinal System Test
1. When planning care for a client with ulcerative colitis who is experiencing symptoms, which client care activities can the nurse appropriately delegate to a unlicensed assistant?
- A. Assessing the client's bowel sounds
- B. administration of pain medication every 4 hours
- C. Evaluating the client's response to antidiarrheal medications
- D. Maintaining intake and output records
Correct answer: D
Rationale: Delegating tasks such as providing skin care, maintaining intake and output records, and obtaining the client's weight are within the scope of practice for an unlicensed assistant. Assessing bowel sounds and evaluating the response to medications require nursing judgment and should not be delegated.
2. Sharon has cirrhosis of the liver and develops ascites. What intervention is necessary to decrease the excessive accumulation of serous fluid in her peritoneal cavity?
- A. Restrict fluids
- B. Encourage ambulation
- C. Increase sodium in the diet
- D. Give antacids as prescribed
Correct answer: A
Rationale: Restricting fluids is necessary to decrease the excessive accumulation of serous fluid in the peritoneal cavity for a patient with ascites due to cirrhosis.
3. You’re performing an abdominal assessment on Brent who is 52 y.o. In which order do you proceed?
- A. Observation, percussion, palpation, auscultation
- B. Observation, auscultation, percussion, palpation
- C. Percussion, palpation, auscultation, observation
- D. Palpation, percussion, observation, auscultation
Correct answer: B
Rationale: The correct order for performing an abdominal assessment is observation, auscultation, percussion, and palpation.
4. An intubated patient is receiving continuous enteral feedings through a Salem sump tube at a rate of 60ml/hr. Gastric residuals have been 30-40ml when monitored Q4H. You check the gastric residual and aspirate 220ml. What is your first response to this finding?
- A. Notify the doctor immediately.
- B. Stop the feeding, and clamp the NG tube.
- C. Discard the 220ml, and clamp the NG tube.
- D. Give a prescribed GI stimulant such as metoclopramide (Reglan).
Correct answer: B
Rationale: If gastric residuals are high during continuous enteral feedings, the first response is to stop the feeding and clamp the NG tube.
5. When planning care for a client with ulcerative colitis who is experiencing symptoms, which client care activities can the nurse appropriately delegate to a unlicensed assistant?
- A. Assessing the client's bowel sounds
- B. Providing skin care following bowel movements
- C. Evaluating the client's response to antidiarrheal medications
- D. administration of pain medication every 4 hours
Correct answer: B
Rationale: Providing skin care following bowel movements, maintaining intake and output records, and obtaining the client's weight can be delegated to a unlicensed assistant.
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