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

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?

A. Notify the doctor immediately.
B. Stop the feeding, and clamp the NG tube.
C. Discard the 220ml, and clamp the NG tube.
D. Give a prescribed GI stimulant such as metoclopramide (Reglan).

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. The nurse has provided home care instructions to a client who had a subtotal gastrectomy. The nurse instructs the client regarding the signs and symptoms associated with dumping syndrome. Which of the following signs and symptoms, if identified by the client, indicates an understanding of this potential complication following gastrointestinal surgery?

A. Hiccups and diarrhea
B. Fatigue and abdominal pain
C. Constipation and fever
D. Diaphoresis and diarrhea

Correct answer: D

Rationale: The correct answer is D: Diaphoresis and diarrhea. Dumping syndrome occurs after gastric surgery when food moves quickly from the stomach to the intestine, causing fluid shifts and leading to symptoms like weakness, dizziness, diaphoresis, flushing, hypotension, abdominal pain, distension, hyperactive bowel sounds, and diarrhea. Choices A, B, and C do not reflect the typical signs and symptoms of dumping syndrome.

3. A client with a peptic ulcer is scheduled for a vagotomy. The client asks the nurse about the purpose of this procedure. The nurse tells the client that the procedure:

A. Decreases food absorption in the stomach
B. Heals the gastric mucosa
C. Halts stress reactions
D. Reduces the stimulus to acid secretions

Correct answer: D

Rationale: A vagotomy reduces the stimulus to acid secretions by cutting the vagus nerve, which innervates the stomach.

4. Which of the following symptoms best describes Murphyâ€™s sign?

A. Periumbilical ecchymosis exists
B. On deep palpation and release, pain is elicited
C. On deep inspiration, pain is elicited and breathing stops
D. Abdominal muscles are tightened in anticipation of palpation

Correct answer: C

Rationale: Murphy's sign is described as pain elicited on deep inspiration when the examiner's fingers are placed under the right costal margin.

5. Which of the following nursing measures would be inappropriate when caring for a client with a Cantor tube?

A. Injecting 10 mL of air into the tube to facilitate drainage.
B. Applying a water-soluble lubricant to the client's nares.
C. Coiling extra tubing on the client's bed.
D. Irrigating the tube with 50 mL of normal saline solution.

Correct answer: D

Rationale: Intestinal tubes are not irrigated. Injecting air into the tube, applying water-soluble lubricant, and coiling extra tubing are appropriate nursing measures.