ATI RN
Gastrointestinal System Nursing Exam Questions
1. A nurse is developing a plan of care for a client who will be returning to a nursing unit following a percutaneous transhephatic cholangiogram. The nurse includes which intervention in the postprocedure plan of care?
- A. Place a sandbag over the insertion site.
- B. Allow the client bathroom privileges only.
- C. Encourage fluid intake.
- D. Allow the client to sit in a chair for meals.
Correct answer: A
Rationale: Following this procedure, the nurse monitors the client’s vital signs closely for indications of hemorrhage and observes the needle insertion site for bleeding and bile leakage. A sandbag is placed over the insertion site to prevent bleeding. The client is maintained on bedrest, and oral intake is avoided in the immediate postprocedure period in case surgery is necessary to control hemorrhage of bile extravasation.
2. Elmer is scheduled for a proctoscopy and has an I.V. The doctor wrote an order for 5mg of I.V. diazepam(Valium). Which order is correct regarding diazepam?
- A. Give diazepam in the I.V. port closest to the vein.
- B. Mix diazepam with 50 ml of dextrose 5% in water and give over 15 minutes.
- C. Give diazepam rapidly I.V. to prevent the bloodstream from diluting the drug mixture.
- D. Question the order because I.V. administration of diazepam is contraindicated.
Correct answer: A
Rationale: The correct method for administering I.V. diazepam is to give it in the I.V. port closest to the vein.
3. A nurse is preparing to mix NPH and regular insulin in the same syringe. Which of the following actions should the nurse take?
- A. Inject air into the NPH insulin vial.
- B. Withdraw the prescribed dose of regular insulin.
- C. Withdraw the prescribed dose of NPH insulin.
- D. Mix the two insulins in separate syringes.
Correct answer: A
Rationale: When mixing NPH and regular insulin in the same syringe, the nurse should first inject air into the NPH insulin vial. This action prevents contamination by allowing an easier withdrawal of the correct dose of NPH insulin after withdrawing the regular insulin. Withdrawing the prescribed dose of regular insulin (Choice B) is incorrect as it does not address the initial step of injecting air into the NPH vial. Similarly, withdrawing the prescribed dose of NPH insulin (Choice C) is incorrect as it skips the crucial first step. Mixing the two insulins in separate syringes (Choice D) is not ideal since combining them in one syringe is a common practice to reduce the number of injections for the patient.
4. A client with a new diagnosis of diabetes mellitus is being taught about foot care. What instruction should the nurse include?
- A. Apply lotion between the toes after bathing
- B. Wear shoes at all times
- C. Cut toenails in a rounded shape
- D. Inspect the feet weekly
Correct answer: B
Rationale: The correct answer is to wear shoes at all times. This instruction is vital for clients with diabetes mellitus as it helps protect the feet and reduces the risk of injury. Option A is incorrect as applying lotion between the toes can increase moisture and the risk of fungal infections. Option C is incorrect as cutting toenails in a rounded shape may lead to ingrown toenails. Option D is also incorrect as inspecting the feet weekly is not sufficient for proper foot care in clients with diabetes mellitus.
5. What is one focus of current health care?
- A. Increased provision of nursing services
- B. Disease prevention
- C. Symptom management
- D. Identification of disease processes
Correct answer: B
Rationale: The correct answer is 'Disease prevention.' Modern healthcare places emphasis on preventing diseases to enhance overall health and well-being. While nursing services, symptom management, and disease identification are crucial components of healthcare, disease prevention plays a key role in reducing the burden of illness on individuals and communities.
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