ATI RN
ATI Gastrointestinal System Quizlet
1. Five days after undergoing surgery, a client develops a small-bowel obstruction. A Miller-Abbott tube is inserted for bowel decompression. Which nursing diagnosis takes priority?
- A. Imbalanced nutrition: Less than body requirements
- B. Acute pain
- C. Deficient fluid volume
- D. Excess fluid volume
Correct answer: C
Rationale: For a client with a small-bowel obstruction and a Miller-Abbott tube, deficient fluid volume is the priority nursing diagnosis.
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?
- A. Assessing the client's bowel sounds
- B. Providing skin care following bowel movements
- C. Evaluating the client's response to antidiarrheal medications
- D. administration of pain medication every 4 hours
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. The nurse is teaching the client how to perform a colostomy irrigation. To enhance the effectiveness of the irrigation and fecal returns, what measure should the nurse instruct the client to do?
- A. Increase fluid intake
- B. Reduce the amount of irrigation solution
- C. Perform the irrigation in the evening
- D. Place heat on the abdomen
Correct answer: A
Rationale: Increasing fluid intake helps to enhance the effectiveness of colostomy irrigation by softening the stool and promoting better fecal return.
4. A client with liver dysfunction has low serum levels of thrombin. The nurse provides care, anticipating that this client is most at risk of
- A. Dehydration
- B. Malnutrition
- C. Bleeding
- D. Infection
Correct answer: C
Rationale: Thrombin is produced by the liver and is necessary for normal clotting. When a client with liver dysfunction has low serum levels of thrombin, they are at risk of bleeding due to impaired clotting mechanisms. Dehydration (choice A) is not directly related to low thrombin levels. Malnutrition (choice B) may impact overall health but is not the most immediate concern associated with low thrombin levels. Infection (choice D) is not directly related to the clotting function affected by low thrombin levels.
5. The nurse is caring for a client with cirrhosis. Which manifestations indicate deficient vitamin K absorption caused by this liver disease?
- A. Dyspnea and fatigue
- B. Ascites and orthopnea
- C. Purpura and petechiae
- D. Gynecomastia and testicular atrophy
Correct answer: C
Rationale: A liver disorder, such as cirrhosis, can disrupt the liver's normal use of vitamin K to produce prothrombin (a clotting factor). Because of this, the nurse should monitor the client for signs of bleeding, including purpura and petechiae. Dyspnea and fatigue suggest anemia. Ascites and orthopnea are unrelated to vitamin K absorption. Gynecomastia and testicular atrophy result from decreased estrogen metabolism by the diseased liver.
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