ATI RN
ATI Gastrointestinal System Test
1. Annebell is being discharged with a colostomy, and you’re teaching her about colostomy care. Which statement correctly describes a healthy stoma?
- A. At first, the stoma may bleed slightly when touched.
- B. The stoma should appear dark and have a bluish hue.
- C. A burning sensation under the stoma faceplate is normal.
- D. The stoma should remain swollen away from the abdomen.
Correct answer: A
Rationale: A healthy stoma may bleed slightly when touched initially, which is normal.
2. A nurse is assessing a client who is receiving opioid analgesics for pain management. Which of the following findings should the nurse report to the provider?
- A. Respiratory rate of 20/min
- B. Blood pressure of 118/76 mm Hg
- C. Heart rate of 88/min
- D. Oxygen saturation of 94%
Correct answer: C
Rationale: The correct answer is C. A heart rate of 88/min is a normal finding; therefore, it does not require immediate reporting to the provider. The respiratory rate of 20/min, blood pressure of 118/76 mm Hg, and oxygen saturation of 94% are also within normal ranges and do not indicate any immediate concerns. However, a serum potassium level of 3.0 mEq/L indicates hypokalemia, which can be a serious issue and should be reported to the provider for further evaluation and management.
3. What is the nurse’s priority action for a client with compromised immunity?
- A. Wash hands before entering the client’s room
- B. Take the client’s vital signs every 4 hours
- C. Determine whether it is temporary or permanent
- D. Teach the family members to receive the flu shot annually
Correct answer: Wash hands before entering the client’s room
Rationale:
4. Which factor has been shown to increase the risk of development of atherosclerosis?
- A. Menopause
- B. Age older than 35
- C. Increased levels of arachidonic acid
- D. Elevated HDL cholesterol
Correct answer: A: Menopause
Rationale: The correct answer is A: Menopause. Menopause is associated with an increased risk of atherosclerosis due to hormonal changes that affect lipid profiles and vascular health. Conversely, B: Age older than 35 is not necessarily a risk factor for atherosclerosis on its own, though atherosclerosis risk does generally increase with age. C: Increased levels of arachidonic acid is not specifically linked to atherosclerosis; it's a fatty acid that can be both beneficial and harmful to health depending on its metabolic pathway. D: Elevated HDL cholesterol is actually beneficial rather than harmful because HDL cholesterol is known as 'good' cholesterol that helps to reduce the risk of heart disease and atherosclerosis.
5. A healthcare provider is reviewing laboratory results for a client who is receiving heparin therapy. Which of the following results indicates that the medication is effective?
- A. Platelets 250,000/mm³
- B. aPTT 60 seconds
- C. Hemoglobin 15 g/dL
- D. INR 1.5
Correct answer: B
Rationale: An aPTT of 60 seconds indicates that the client is receiving an effective dose of heparin. The activated partial thromboplastin time (aPTT) measures the time it takes for blood to clot and is used to monitor heparin therapy. A therapeutic range for aPTT during heparin therapy is usually 1.5 to 2 times the control value, which is around 25-35 seconds. Platelets, hemoglobin, and INR values are not direct indicators of the effectiveness of heparin therapy.
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