ATI RN
Gastrointestinal System Nursing Exam Questions
1. A nurse has been caring for a client with a Sengstaken-Blakemore tube. The physician arrives on the nursing unit and deflates the esophageal balloon. The nurse should monitor the client most closely for which of the following?
- A. Swelling of the abdomen
- B. Bloody diarrhea
- C. Vomiting blood
- D. An elevated temperature and arise in blood pressure
Correct answer: C
Rationale: A Sengstaken-Blakemore tube is inserted into a client with a diagnosis of cirrhosis and ruptured esophageal varices. The tube has an esophageal and a gastric balloon. The esophageal balloon exerts pressure on the bleeding. The pressure of the esophageal balloon is released at intervals to decrease the risk of trauma to esophageal tissues, including esophageal rupture or necrosis. When the balloon is deflated the client may begin to bleed again from the esophageal varices, noted by vomiting of blood.
2. During an emergency response following a disaster, which client should be recommended for early discharge?
- A. A client with COPD and a respiratory rate of 44/min.
- B. A client with cancer and a sealed implant for radiation therapy.
- C. A client receiving heparin for deep-vein thrombosis.
- D. A client who is 1 day postoperative following a vertebroplasty.
Correct answer: D
Rationale: The client who is 1 day postoperative following a vertebroplasty is stable and can be discharged early. In an emergency response situation, it is crucial to prioritize clients who are medically stable and do not require immediate hospital care. The client with COPD and a respiratory rate of 44/min needs close monitoring and intervention. The client with cancer and a sealed implant for radiation therapy requires specialized care and follow-up. The client receiving heparin for deep-vein thrombosis needs ongoing anticoagulant therapy and monitoring, making early discharge not appropriate.
3. A nurse administers naloxone (Narcan) to a post-op patient experiencing respiratory sedation. What undesirable effect would the nurse anticipate after giving this medication?
- A. Drowsiness
- B. Tics and tremors
- C. Increased Pain
- D. Nausea and vomiting
Correct answer: C
Rationale: Naloxone reverses the effects of narcotics. Although the patient�s respiratory status will improve after administration of naloxone, the pain will be more acute.
4. A client with hypertension is being taught about dietary modifications by a nurse. Which of the following food choices by the client indicates an understanding of the teaching?
- A. I will choose processed meats for meals.
- B. I will eat canned vegetables to reduce my sodium intake.
- C. I will eat fresh fruits and vegetables each day.
- D. I will increase my intake of canned soups.
Correct answer: C
Rationale: The correct answer is C. Choosing fresh fruits and vegetables is a healthy choice for someone with hypertension as they are low in sodium and high in nutrients. Processed meats (A) are high in sodium and unhealthy fats, which can worsen hypertension. Canned vegetables (B) often have added sodium, so fresh is a better choice. Canned soups (D) are typically high in sodium and should be limited in a hypertensive diet.
5. A nurse is caring for a client who has experienced intimate partner violence. What is the nurse's priority?
- A. Develop a safety plan with the client.
- B. Refer the client to a community support group.
- C. Determine if the client has any injuries.
- D. Contact the client's family about the incident.
Correct answer: A
Rationale: The correct answer is A: 'Develop a safety plan with the client.' When caring for a client who has experienced intimate partner violence, the nurse's priority is to ensure the client's safety. Developing a safety plan is essential to address the immediate safety concerns and provide support to the client. Referring the client to a community support group, as in option B, may be beneficial but is not the immediate priority. While determining if the client has any injuries, as in option C, is important for assessing physical well-being, the priority is to address safety concerns first. Contacting the client's family about the incident, as in option D, is not appropriate without the client's consent and may further endanger the client.
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