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. When planning care for a client with ulcerative colitis who is experiencing symptoms, which client care activities can the nurse appropriately delegate to a unlicensed assistant?

Correct answer: B

Rationale: Providing skin care following bowel movements, maintaining intake and output records, and obtaining the client's weight can be delegated to a unlicensed assistant.

3. A client with 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

Correct answer: D

Rationale: A vagotomy, or cutting of the vagus nerve, is done to eliminate parasympathetic stimulation of gastric secretion, thereby reducing the stimulus to acid secretions. Options A, B, and C are incorrect as a vagotomy does not affect food absorption, heal the gastric mucosa, or halt stress reactions.

4. Which area of the alimentary canal is the most common location for Crohn’s disease?

Correct answer: D

Rationale: The terminal ileum is the most common location for Crohn's disease.

5. Which of the following nursing interventions should have the highest priority during the first hour after the admission of a client with cholecystitis who is experiencing pain, nausea, and vomiting?

Correct answer: A

Rationale: Administering pain medication would have the highest priority during the first hour after the client's admission. Pain relief is essential to address the client's immediate discomfort and distress. Completing the admission history, maintaining hydration, and teaching about planned diagnostic tests are important aspects of care but can be addressed after addressing the client's pain and stabilizing their condition.

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