ATI RN
ATI Gastrointestinal System
1. A client with liver dysfunction has low serum levels of thrombin. The nurse provides care, anticipating that this client is most at risk of
- A. Dehydration
- B. Malnutrition
- C. Bleeding
- D. Infection
Correct answer: C
Rationale: Thrombin is produced by the liver and is necessary for normal clotting. When a client with liver dysfunction has low serum levels of thrombin, they are at risk of bleeding due to impaired clotting mechanisms. Dehydration (choice A) is not directly related to low thrombin levels. Malnutrition (choice B) may impact overall health but is not the most immediate concern associated with low thrombin levels. Infection (choice D) is not directly related to the clotting function affected by low thrombin levels.
2. A client is taking Spironolactone. Which of the following laboratory findings should the nurse monitor and report to the provider?
- A. Sodium level of 138 mEq/L
- B. Potassium level of 5.2 mEq/L
- C. Chloride level of 100 mEq/L
- D. Calcium level of 9.5 mg/dL
Correct answer: B
Rationale: The correct answer is B: Potassium level of 5.2 mEq/L. Spironolactone is a potassium-sparing diuretic that can lead to hyperkalemia (elevated potassium levels). A potassium level of 5.2 mEq/L is considered elevated and should be reported to the provider for further assessment and management to prevent potential complications. Choices A, C, and D are not directly affected by Spironolactone and do not typically require immediate reporting unless there are other underlying issues or specific instructions for those electrolytes.
3. Does the digestive system filter wastes from the blood?
- A. True
- B. False
- C. Not Sure
- D. None of the above
Correct answer: False
Rationale: The correct answer is False. The digestive system is responsible for breaking down food and absorbing nutrients, not filtering wastes from the blood. The excretory system, particularly the kidneys, filters wastes from the blood to form urine. Choices A, C, and D are incorrect because the digestive system's primary function is not waste filtration but rather digestion and absorption of nutrients.
4. The client with a new colostomy is concerned about the odor from stool from the ostomy drainage bag. The nurse teaches the client to include which of the following foods in the diet to reduce odor?
- A. Yogurt
- B. Broccoli
- C. Cucumbers
- D. Eggs
Correct answer: A
Rationale: The client should be taught to include deodorizing foods in the diet, such as beet greens, parsley, buttermilk, and yogurt. Spinach also reduces odor but is a gas-forming food as well. Broccoli, cucumber, and eggs are gas-forming foods.
5. A nurse is planning care of an adolescent who is postoperative following a lumbar laminectomy. Which of the following interventions should the nurse include in the plan of care?
- A. Limit the adolescent's visitors.
- B. Select the adolescent's food choices.
- C. Encourage the adolescent's guardian to assist with personal hygiene.
- D. Allow the adolescent to make decisions regarding their daily routine.
Correct answer: C
Rationale: The correct answer is C because after a lumbar laminectomy, the adolescent may need assistance with personal hygiene due to limited mobility and pain. Encouraging the guardian to assist with personal hygiene ensures proper care and prevents complications. Choice A is incorrect as limiting visitors may affect the adolescent's emotional well-being and support system. Choice B is incorrect as the adolescent should have autonomy in selecting their food choices as long as they align with their dietary restrictions post-surgery. Choice D is incorrect as the adolescent may need guidance and support in decision-making during the postoperative period.
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