an intubated patient is receiving continuous enteral feedings through a salem sump tube at a rate of 60mlhr gastric residuals have been 30 40ml when m
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Nursing Elites

ATI RN

ATI Gastrointestinal System Test

1. An intubated patient is receiving continuous enteral feedings through a Salem sump tube at a rate of 60ml/hr. Gastric residuals have been 30-40ml when monitored Q4H. You check the gastric residual and aspirate 220ml. What is your first response to this finding?

Correct answer: B

Rationale: If gastric residuals are high during continuous enteral feedings, the first response is to stop the feeding and clamp the NG tube.

2. During an abdominal assessment, a nurse finds pulsation between the umbilicus and pubis on a client. What finding should be reported to the physician?

Correct answer: B

Rationale: The presence of pulsation between the umbilicus and pubis could indicate an abdominal aortic aneurysm, which is a serious condition and should be reported to the physician promptly. A concave, midline umbilicus is a normal finding. Bowel sound frequency can vary widely and is not a cause for concern at 15 sounds per minute. Absence of a bruit is a normal finding in an abdominal assessment and does not require reporting.

3. Which of the following symptoms may be exhibited by a client with Crohn’s disease?

Correct answer: D

Rationale: Clients with Crohn's disease may exhibit symptoms such as steatorrhea, which is the presence of excess fat in the stool.

4. The nurse is preparing to discontinue a client’s nasogastric tube. The client is positioned properly, and the tube has been flushed with 15 mL of air to clear secretions. Before removing the tube, the nurse makes which statement to the client?

Correct answer: C

Rationale: The client should take a deep breath because the client’s airway will be obstructed temporarily during tube removal. The nurse then tells the client to exhale slowly and withdraws the tube during exhalation. Bearing down could inhibit the removal of the tube. Breathing normally could result in aspiration of gastric secretions during inhalation. Holding the breath does not facilitate tube removal.

5. A client with peptic ulcer disease tells the nurse that he has black stools, which he has not reported to his physician. Based on this information, which nursing diagnosis would be appropriate for this client?

Correct answer: B

Rationale: Deficient knowledge related to unfamiliarity with significant signs and symptoms is appropriate because the client did not report the black stools, which can be a sign of bleeding.

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