ATI RN
ATI Gastrointestinal System Test
1. After abdominal surgery, your patient has a severe coughing episode that causes wound evisceration. In addition to calling the doctor, which intervention is most appropriate?
- A. Irrigate the wound & organs with Betadine.
- B. Cover the wound with a saline soaked sterile dressing.
- C. Apply a dry sterile dressing & binder.
- D. Push the organs back & cover with moist sterile dressings.
Correct answer: B
Rationale: Covering the wound with a saline soaked sterile dressing is the most appropriate intervention for wound evisceration.
2. Cultural diversity presents an important challenge to nurse managers due to which of the following?
- A. A nursing shortage exists
- B. Staff nurses are not trained to be culturally sensitive
- C. 80% of nursing staff comes from one or more minority groups
- D. The increase in cultural diversity is seen both in the patient population and the nursing staff
Correct answer: D
Rationale: Cultural diversity presents an important challenge to nurse managers due to the increase in cultural diversity seen both in the patient population and the nursing staff. This challenge requires nurse managers to ensure that their nursing staff can effectively communicate and provide culturally competent care to patients from diverse backgrounds. Choice A is incorrect because it does not directly relate to the impact of cultural diversity. Choice B is incorrect as it focuses on the training of staff nurses rather than the overall challenge of managing cultural diversity. Choice C is incorrect as the percentage of nursing staff from minority groups, while important, is not the primary reason cultural diversity poses a challenge to nurse managers.
3. A nurse is caring for a client receiving IV vancomycin. The nurse notes flushing of the client's neck and chest. Which of the following actions should the nurse take?
- A. Stop the infusion
- B. Document the findings as a harmless reaction
- C. Slow the infusion rate
- D. Administer diphenhydramine
Correct answer: C
Rationale: The correct action for the nurse to take when a client receiving IV vancomycin shows flushing of the neck and chest is to slow the infusion rate. Flushing is a common sign of Red Man Syndrome, which is associated with rapid infusions of vancomycin. Slowing down the infusion rate can help prevent further flushing and the development of Red Man Syndrome. Stopping the infusion (Choice A) may be too drastic if the symptoms are mild and can be managed by slowing the rate. Documenting the findings as a harmless reaction (Choice B) is incorrect because flushing should be addressed promptly to prevent complications. Administering diphenhydramine (Choice D) is not the initial or best intervention for flushing associated with vancomycin; slowing the infusion rate is the priority.
4. What is the most appropriate nursing diagnosis for the client's son based on the information provided?
- A. Risk for other-directed violence
- B. Disturbed sleep pattern
- C. Caregiver role strain
- D. Social isolation
Correct answer: C
Rationale: The correct answer is 'Caregiver role strain.' In the scenario presented, the son expresses that his father's constant confusion, incontinence, and tendency to wander are intolerable. These challenges indicate that the son is experiencing strain in his role as a caregiver. 'Risk for other-directed violence' is not appropriate because there is no indication of violent behavior. 'Disturbed sleep pattern' is not the most relevant nursing diagnosis given the information provided. 'Social isolation' is not the most appropriate choice as the son's concerns are related to the challenges of caregiving, not isolation.
5. What is a condition where the heart's ability to pump blood is decreased, leading to fluid buildup in the lungs and other parts of the body?
- A. Heart failure
- B. Cardiomyopathy
- C. Pericarditis
- D. Myocarditis
Correct answer: A
Rationale: The correct answer is A, heart failure. Heart failure is a condition where the heart is unable to pump blood effectively, leading to fluid accumulation in the lungs and other areas. Choice B, Cardiomyopathy, refers to diseases of the heart muscle. Choices C and D, Pericarditis and Myocarditis, respectively, are conditions involving inflammation of the outer lining of the heart and the heart muscle itself, which may not always directly result in decreased pumping ability like heart failure does.
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