ATI RN
Gastrointestinal System Nursing Exam Questions
1. A nurse orientee is preparing to insert a nasogastric tube, and a nurse educator is observing the procedure. Which of the following supplies if obtained by the nurse orientee would indicate a need for further education regarding this procedure?
- A. Half-inch or one-inch tape
- B. Oil-soluble lubricant
- C. A glass of tap water with a straw
- D. A 50-mL catheter tip syringe
Correct answer: B
Rationale: Water-soluble lubricant is used to lubricate 3 to 4 inches of the tube at the insertion end. An oil lubricant is not used because if the tube accidentally goes into the bronchus, pneumonia can develop. Half-inch tape is used to secure the tube after the correct placement is verified. A 50-mL catheter tip syringe is used to aspirate gastric contents to confirm placement. The client will be asked to take a sip of water through a straw to help with the passage of the tube.
2. What findings on physical assessment of a neonate would indicate the need for further evaluation?
- A. Nystagmus
- B. Epstein pearls
- C. Low-set ears
- D. Positive Babinski reflex
Correct answer: C
Rationale: Low-set ears in a neonate suggest major abnormalities and should prompt further evaluation. The correct alignment of the top of the pinnae of the ear with the outer canthus of the eye is crucial. Nystagmus, an involuntary eye movement, is common in newborns and often resolves on its own. Epstein pearls, small cysts on the hard palate, are insignificant and disappear over time. A positive Babinski reflex is normal in infants up to 1 year of age. Therefore, the presence of low-set ears is the most concerning finding that requires immediate attention.
3. A client has a new prescription for Clozapine. Which of the following statements should the nurse include in the teaching?
- A. You should have a high-carbohydrate snack between meals and at bedtime.
- B. You are likely to develop hand tremors if you take this medication for a long period of time.
- C. You may experience temporary numbness of your mouth after each dose.
- D. You should have your white blood cell count monitored every week.
Correct answer: D
Rationale: Clozapine carries a risk for fatal agranulocytosis. To monitor for this serious adverse effect, it is crucial to check the client's white blood cell count weekly while they are on clozapine therapy.
4. Which of the following best describes intrinsic values?
- A. Intrinsic values are often abstract ideas.
- B. Intrinsic values are basic needs for sustaining life.
- C. Intrinsic values are qualities patients consider to be important in their private lives.
- D. Intrinsic values are qualities patients consider important for nurses to have.
Correct answer: B
Rationale: The correct answer is B. Intrinsic values refer to basic needs for sustaining life, such as food, water, shelter, and safety. Choices A, C, and D are incorrect because intrinsic values are not abstract ideas, qualities important in private lives, or qualities important for nurses to have.
5. What causes secondary brain injury after head trauma?
- A. Brain injury resulting from the body’s response to tissue damage
- B. Brain injury resulting from initial trauma
- C. Injury as a result of medical therapy
- D. Focal areas of bleeding
Correct answer: A
Rationale: The correct answer is A. Secondary brain injury occurs due to the body's response to the initial trauma, which can worsen the effects of the primary injury. This response includes processes like inflammation, increased intracranial pressure, and reduced oxygen delivery to tissues. Choice B is incorrect because it refers to the primary trauma itself, not the secondary injury. Choice C is incorrect as it relates to injury caused by medical interventions rather than the body's response. Choice D is incorrect as it specifically mentions focal areas of bleeding, which is a consequence of trauma rather than the cause of secondary brain injury.
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