a nurse is performing an assessment on a client with a suspected diagnosis of acute pancreatitis the nurse assesses the client knowing that which of t
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ATI RN

Gastrointestinal System Nursing Exam Questions

1. A nurse is performing an assessment on a client with a suspected diagnosis of acute pancreatitis. The nurse assesses the client, knowing that which of the following is a hallmark sign of this disorder?

Correct answer: B

Rationale: A hallmark sign of acute pancreatitis is severe abdominal pain that is not relieved by vomiting. Nausea and vomiting are common presenting symptoms, with vomitus typically consisting of gastric and duodenal contents. Hypothermia is not a hallmark sign of acute pancreatitis. Fever, typically less than 38 degrees centigrade, is more common. Epigastric pain radiating to the neck area is not a characteristic sign of acute pancreatitis. Therefore, choice B is the correct answer.

2. You are developing a careplan on Sally, a 67 y.o. patient with hepatic encephalopathy. Which of the following do you include?

Correct answer: A

Rationale: Administering a lactulose enema as ordered helps reduce ammonia levels in patients with hepatic encephalopathy.

3. You’re caring for Beth who underwent a Billroth II procedure (surgical removal of the pylorus and duodenum) for treatment of a peptic ulcer. Which findings suggest that the patient is developing dumping syndrome, a complication associated with this procedure?

Correct answer: C

Rationale: Dizziness and sweating are common signs of dumping syndrome, a complication of the Billroth II procedure.

4. When planning care for a client with ulcerative colitis who is experiencing symptoms, which client care activities can the nurse appropriately delegate to a unlicensed assistant?

Correct answer: D

Rationale: Delegating tasks such as providing skin care, maintaining intake and output records, and obtaining the client's weight are within the scope of practice for an unlicensed assistant. Assessing bowel sounds and evaluating the response to medications require nursing judgment and should not be delegated.

5. You have a patient with achalasia (incomplete muscle relaxation of the GI tract, especially sphincter muscles). Which medications do you anticipate to administer?

Correct answer: A

Rationale: Isosorbide dinitrate (Isordil) is a medication used to relax the muscles of the GI tract in patients with achalasia.

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