ATI RN
ATI Gastrointestinal System
1. 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.
2. A nurse is caring for a client who has a history of angina. The client reports chest pain. Which of the following actions should the nurse take?
- A. Administer sublingual nitroglycerin every 5 minutes
- B. Administer aspirin 325 mg
- C. Encourage the client to use deep breathing exercises
- D. Apply oxygen at 2 L/min via nasal cannula
Correct answer: A
Rationale: The correct action for the nurse to take when a client with a history of angina reports chest pain is to administer sublingual nitroglycerin every 5 minutes. Nitroglycerin helps dilate blood vessels, improving blood flow to the heart and relieving chest pain associated with angina. Aspirin is often given during a suspected heart attack, not for immediate relief of angina. Deep breathing exercises may be beneficial for anxiety or respiratory conditions but are not the first-line intervention for angina. Oxygen therapy is not the initial treatment for angina unless the client is hypoxic.
3. The nurse is caring for a client with a diagnosis of cirrhosis and is monitoring the client for signs of portal hypertension. Which initial sign, if noted in the client, indicates the presence of portal hypertension?
- A. Flat neck veins
- B. Hypotension
- C. Weak pulse
- D. Crackles on auscultation of the lungs
Correct answer: D
Rationale: Clinical signs and symptoms or portal hypertension are identical to those of heart failure and include jugular vein distention, lung crackles, and decreased perfusion to all organs. Initially, the client may have hypertension, flushed skin, and a bounding pulse.
4. What laboratory finding should the nurse expect in a child with an excess of water?
- A. Decreased hematocrit
- B. High serum osmolality
- C. High urine specific gravity
- D. Increased blood urea nitrogen (BUN)
Correct answer: A
Rationale: Water excess typically leads to hemodilution, resulting in a decreased hematocrit. High serum osmolality and specific gravity would indicate dehydration, while elevated BUN could suggest renal impairment or dehydration, not fluid overload.
5. A nurse is caring for a client who has the following laboratory results: potassium 3.4 mEq/L, magnesium 1.8 mEq/L, calcium 8.5 mEq/L, sodium 144 mEq/L. Which assessment should the nurse complete first?
- A. Assess the client's dietary intake of foods high in potassium.
- B. Assess the client's neuromuscular status.
- C. Assess the client's fluid intake and output.
- D. Read food labels to determine sodium content.
Correct answer: Read food labels to determine sodium content.
Rationale: The correct answer is to read food labels to determine sodium content. The client's sodium level is crucial to monitor as it is on the higher side (144 mEq/L), which can indicate hypernatremia. Excessive sodium intake can lead to fluid retention and other complications. Assessing dietary sodium intake can help the nurse and client make necessary adjustments to prevent further sodium imbalances. Choices A, B, and C are not the priority in this situation as the client's sodium level needs immediate attention to prevent potential complications.
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