a nurse is reviewing the results of serum laboratory studies drawn on a client who is suspected of having hepatitis the nurse interprets that an eleva

ATI RN

Gastrointestinal System Nursing Exam Questions

1. A nurse is reviewing the results of serum laboratory studies drawn on a client who is suspected of having hepatitis. The nurse interprets that an elevation in which of the following studies is the most specific indicator of the disease?

A. Erythrocyte sedimentation rate
B. Serum bilirubin
C. Hemoglobin
D. Blood urea nitrogen

Correct answer: C

Rationale: Laboratory indicators of hepatitis include elevated liver enzymes, serum bilirubin level, and erythrocyte sedimentation rate is nonspecific test that indicates the presence of inflammation somewhere in the body. Elevated blood urea nitrogen may indicate renal dysfunction. A hemoglobin level is unrelated to this diagnosis.

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

A. Administering a lactulose enema as ordered.
B. Encouraging a protein-rich diet.
C. Administering sedatives, as necessary.
D. Encouraging ambulation at least four times a day.

Correct answer: A

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

3. A client is admitted to the hospital with acute viral hepatitis. Which of the following signs or symptoms would the nurse expect to note based on this diagnosis?

A. Spider angiomas
B. Fatigue
C. Pale urine
D. Weight gain

Correct answer: B

Rationale: Common signs of acute viral hepatitis include weight loss, dark urine, and fatigue. The client is anorexic, possibly from a toxin produced by the diseased liver, and finds food distasteful. The urine darkens because of excess bilirubin being excreted by the kidneys. Fatigue occurs during all phases of hepatitis.

4. A nurse is caring for a client who has just returned from the operating room following the creation of a colostomy. The nurse is assessing the drainage in the pouch attached to the site where the colostomy was formed and notes serosanguineous drainage. Which nursing action is most appropriate based on this assessment?

A. Notify the physician
B. Document the amount and characteristics of the drainage
C. Apply ice to the stoma site
D. Apply pressure to the site

Correct answer: B

Rationale: During the first 24 to 72 hours following surgery, mucus and serosanguineous drainage are expected from the stoma. Documenting the amount and characteristics of the drainage is appropriate. The nurse does not need to notify the physician because this is an expected finding. Applying ice or pressure to the site is not necessary.