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 th
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Nursing Elites

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?

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. The nurse is caring for a client following a Billroth II procedure. On review of the post-operative orders, which of the following, if prescribed, would the nurse question and verify?

Correct answer: A

Rationale: Irrigating the nasogastric tube is typically not recommended after a Billroth II procedure unless specifically ordered by a physician due to the risk of disrupting the surgical site.

3. The client with GERD complains of a chronic cough. The nurse understands that in a client with GERD this symptom may be indicative of which of the following conditions?

Correct answer: D

Rationale: Aspiration of gastric contents can lead to a chronic cough in clients with GERD.

4. The client with a colostomy has an order for irrigation of the colostomy. The nurse used which solution for irrigation?

Correct answer: B

Rationale: Tap water at body temperature is generally used for colostomy irrigation unless the local water supply is not safe for drinking, in which case bottled water can be used.

5. Before administering an intermittent tube feeding through a nasogastric tube, the nurse assesses for gastric residual. The nurse understands that this procedure is important to

Correct answer: D

Rationale: Evaluating the absorption of the last feeding is important because administration of a tube feeding to a full stomach could result in overdistention, thus predisposing the client to regurgitation and possible aspiration.

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