ATI RN
Gastrointestinal System Nursing Exam Questions
1. A client with viral hepatitis is discussing with the nurse the need to avoid alcohol and states, 'I’m not sure I can avoid alcohol.' The most appropriate response is
- A. Everything will be alright.
- B. I think you should talk more with the doctor about this.
- C. I don’t believe that.
- D. I’m not sure that I don’t understand. Would you please explain?
Correct answer: D
Rationale: The most appropriate response in this situation is to seek clarification from the client by saying, 'I’m not sure that I don’t understand. Would you please explain?' This response shows empathy and a willingness to listen, encouraging the client to elaborate on their concerns. False reassurance (Choice A) is not helpful as it dismisses the client's feelings. Suggesting to talk more with the doctor (Choice B) may deflect from addressing the client's immediate concerns. Expressing disbelief (Choice C) can create a barrier to open communication, making the client feel unsupported.
2. The nurse has inserted a nasogastric tube to the level of the oropharynx and has repositioned the client’s head in a flexed-forward position. The client has been asked to begin swallowing. The nurse starts slowly to advance the nasogastric tube with each swallow. The client begins to cough, gag, and choke. Which nursing action would least likely result in proper tube insertion and promote client relaxation?
- A. Continuing to advance the tube to the desired distance
- B. Pulling the tube back slightly
- C. Checking the back of the pharynx using a tongue blade and flashlight.
- D. Instructing the client to breathe slowly and take sips of water.
Correct answer: A
Rationale: As the nasogastric tube is passed through the oropharynx, the gag reflex is stimulated, which may cause coughing, gagging, or choking. Instead of passing through to the esophagus, the nasogastric tube may coil around itself in the oropharynx, or it may enter the larynx and obstruct the airway, pulling the tube back slightly will remove it from the larynx; advancing the tube might position it in the trachea. Swallowing closes the epiglottis over the trachea and helps move the tube into the esophagus. Slow breathing helps the client relax to reduce the gag response. The nurse should check the back of the client’s throat to note if the tube has coiled. The tube may be advanced after the client relaxes.
3. The nurse is assessing a 71-year-old female client with ulcerative colitis. Which assessment finding related to the family will have the greatest impact on the client's rehabilitation after discharge?
- A. The family's ability to take care of the client's special diet needs
- B. The family's expectation that the client will resume responsibilities and role-related activities
- C. Emotional support from the family
- D. The family's ability to understand the ups and downs of the illness
Correct answer: C
Rationale: Emotional support from the family is the main need. A special diet doesn't focus on emotional needs. Role expectations don't address the main issue, but emotional support while the client is fulfilling these roles is important. The family's ability to understand the ups and downs of the illness will help them but not the client.
4. The nurse is performing an assessment on a client with acute pancreatitis who was admitted to the hospital. Which of the following assessment questions most specifically would elicit information regarding the pain that is associated with acute pancreatitis?
- A. Does the pain in your abdomen radiate to your groin.
- B. Does the pain in your stomach radiate to the back?
- C. Does the pain in your stomach radiate to your lower middle abdomen?
- D. Does the pain in your lower abdomen radiate to the hip?
Correct answer: B
Rationale: The pain that is associated with acute pancreatitis is often severe and is located in the epigastric region and radiates to the back. Options 1, 3, and 4 are incorrect because they are not specific for the pain experienced by the client with pancreatitis.
5. The nurse has provided home care instructions to a client who had a subtotal gastrectomy. The nurse instructs the client regarding the signs and symptoms associated with dumping syndrome. Which of the following signs and symptoms, if identified by the client, indicates an understanding of this potential complication following gastrointestinal surgery?
- A. Hiccups and diarrhea
- B. Fatigue and abdominal pain
- C. Constipation and fever
- D. Diaphoresis and diarrhea
Correct answer: D
Rationale: The correct answer is D: Diaphoresis and diarrhea. Dumping syndrome occurs after gastric surgery when food moves quickly from the stomach to the intestine, causing fluid shifts and leading to symptoms like weakness, dizziness, diaphoresis, flushing, hypotension, abdominal pain, distension, hyperactive bowel sounds, and diarrhea. Choices A, B, and C do not reflect the typical signs and symptoms of dumping syndrome.
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