ATI RN
Gastrointestinal System Nursing Exam Questions
1. A Penrose drain is in place on the first postoperative day following a cholecystectomy. Serosanguineous drainage is noted on the dressing covering the drain. Which nursing intervention is most appropriate?
- A. Notify the physician.
- B. Change the dressing.
- C. Circle the amount on the dressing with a pen.
- D. Continue to monitor the drainage.
Correct answer: B
Rationale: Serosanguineous drainage with a small amount of bile is expected from the Penrose drain for the first 24 hours. Drainage then decreases, and the drain is removed usually within 48 hours. The nurse does not need to notify the physician. A sterile dressing covers the site and should be changed to prevent infection and skin excoriation.
2. James is an 18-month-old child who has had a cough for 7 days with no general danger signs. He has a temperature of 37.5°C and a respiratory rate of 41 breaths/minute. How will you classify James' breathing?
- A. Slow breathing
- B. Fast breathing
- C. Normal breathing
- D. Very fast breathing
Correct answer: C
Rationale: James' breathing is classified as normal because his respiratory rate falls within the expected range for his age group, and there are no general danger signs present. In this case, his breathing is considered normal based on the provided information.
3. A healthcare provider is assessing a client who has COPD and is receiving oxygen therapy at 2 L/min via nasal cannula. Which of the following findings should the provider report?
- A. Oxygen saturation of 95%.
- B. Productive cough with clear sputum.
- C. Respiratory rate of 22/min.
- D. Client reports dyspnea.
Correct answer: D
Rationale: The correct answer is D. Dyspnea in a client with COPD receiving oxygen should be reported as it may indicate worsening respiratory status. Oxygen saturation of 95% is within the expected range for a client receiving oxygen therapy and does not require immediate reporting. A productive cough with clear sputum is a common symptom in clients with COPD and does not necessarily warrant urgent reporting. A respiratory rate of 22/min is also within normal limits and does not raise immediate concerns in this scenario.
4. Which type of medication is used to reduce the workload on the heart by slowing down the heart rate and lowering blood pressure?
- A. Beta-blocker
- B. ACE inhibitor
- C. Calcium channel blocker
- D. Diuretic
Correct answer: A
Rationale: The correct answer is A: Beta-blocker. Beta-blockers are medications that reduce the workload on the heart by slowing down the heart rate and lowering blood pressure. They are commonly used in the treatment of heart conditions such as hypertension and heart failure. ACE inhibitors (B) work by dilating blood vessels to reduce blood pressure, calcium channel blockers (C) prevent calcium from entering the heart muscle and blood vessel walls, and diuretics (D) help the body get rid of excess salt and water by increasing urine production.
5. Which condition can result from prolonged vomiting or diarrhea?
- A. Intracellular fluid
- B. Interstitial fluid
- C. Dehydration
- D. Electrolyte
Correct answer: C
Rationale: The correct answer is C: Dehydration. Prolonged vomiting or diarrhea can lead to significant fluid loss, causing dehydration. Intracellular fluid (choice A) and interstitial fluid (choice B) refer to specific compartments of body fluid and are not conditions resulting from vomiting or diarrhea. Electrolytes (choice D) are minerals that help maintain fluid balance in the body but are not the condition directly resulting from prolonged vomiting or diarrhea.
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