a client with viral hepatitis states i am so yellow the nurse most appropriately would
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Nursing Elites

ATI RN

Gastrointestinal System Nursing Exam Questions

1. A client with viral hepatitis states, 'I am so yellow.' The nurse most appropriately would

Correct answer: A

Rationale: To assist the client in adapting to changes in appearance, the nurse must encourage participation in self-care to foster independence and self-esteem. The nurse should encourage the client to ask questions to clarify misconceptions, learn ways to prevent the spread of hepatitis to reduce fear, and make appropriate decisions. Restricting visitors will reinforce the client’s negative self-esteem.

2. The client has had a new colostomy created 2 days earlier. The client is beginning to pass malodorous flatus from the stoma. The nurse interprets that

Correct answer: B

Rationale: As peristalsis returns following creation of a colostomy, the client begins to pass malodorous flatus. This indicates returning bowel function and is an expected event. Within 72 hours of surgery, the client should begin passing stool via the colostomy.

3. 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?

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.

4. The student nurse is participating in colorectal cancer-screening program. Which patient has the fewest risk factors for colon cancer?

Correct answer: C

Rationale: Herman, a 60 y.o. who follows a low-fat, high-fiber diet, has the fewest risk factors for colon cancer.

5. A nurse orientee is preparing to insert a nasogastric tube, and a nurse educator is observing the procedure. Which of the following supplies if obtained by the nurse orientee would indicate a need for further education regarding this procedure?

Correct answer: B

Rationale: Water-soluble lubricant is used to lubricate 3 to 4 inches of the tube at the insertion end. An oil lubricant is not used because if the tube accidentally goes into the bronchus, pneumonia can develop. Half-inch tape is used to secure the tube after the correct placement is verified. A 50-mL catheter tip syringe is used to aspirate gastric contents to confirm placement. The client will be asked to take a sip of water through a straw to help with the passage of the tube.

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Which of the following tests should be administered to a client suspected of having diverticulosis?
A client with viral hepatitis has no appetite, and food makes the client nauseated. Which of the following interventions would be most appropriate?
The nurse instructs the nursing assistant on how to provide oral hygiene for a client who cannot perform this task for himself. Which of the following techniques should the nurse tell the assistant to incorporate into the client’s daily care?
Annebell is being discharged with a colostomy, and you’re teaching her about colostomy care. Which statement correctly describes a healthy stoma?

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