ATI RN
ATI Gastrointestinal System
1. Mucosal barrier fortifiers are used in peptic ulcer disease management for which of the following indications?
- A. To inhibit mucus production
- B. To neutralize acid production
- C. To stimulate mucus production
- D. To stimulate hydrogen ion diffusion back into the mucosa
Correct answer: C
Rationale: Mucosal barrier fortifiers stimulate mucus production, which helps protect the lining of the stomach and manage peptic ulcer disease.
2. A nurse is developing a care plan for a client who is receiving nitroprusside for severe hypertension. Which action should the nurse include?
- A. Administer calcium gluconate at the bedside.
- B. Monitor blood pressure every 2 hours.
- C. Limit light exposure to the infusion.
- D. Keep the client on NPO status.
Correct answer: C
Rationale: The correct action the nurse should include in the care plan for a client receiving nitroprusside for severe hypertension is to limit light exposure to the infusion. Nitroprusside is light-sensitive, so it should be protected from light exposure to prevent degradation. Administering calcium gluconate at the bedside is not directly related to nitroprusside administration. Monitoring blood pressure every 2 hours is a good practice but is not specifically related to the administration of nitroprusside. Keeping the client on NPO status is not necessary solely based on receiving nitroprusside.
3. The client diagnosed with acute vein thrombosis is receiving a continuous heparin drip, an intravenous anticoagulant. The health care provider orders warfarin (Coumadin), an oral anticoagulant. Which action should the nurse take?
- A. Discontinue the heparin drip before initiating the Coumadin
- B. Check the client’s INR before beginning Coumadin
- C. Clarify the order with the healthcare provider as soon as possible
- D. Administer the Coumadin along with the heparin drip as ordered
Correct answer: D
Rationale: The correct answer is to administer the Coumadin along with the heparin drip as ordered. Heparin and warfarin are often given together initially because warfarin takes a few days to become effective. Discontinuing the heparin drip before initiating Coumadin can increase the risk of clot formation. Checking the client's INR before starting Coumadin is important but not the immediate action required. Clarifying the order with the healthcare provider is not necessary as both medications are commonly used together.
4. Vygotsky saw __________ as the foundation for all higher cognitive processes.
- A. egocentrism
- B. language
- C. sensorimotor activity
- D. self-reflection
Correct answer: B
Rationale: Corrected Rationale: Vygotsky believed that language plays a crucial role in the development of higher cognitive functions. Language enables individuals to communicate, think abstractly, and engage in complex problem-solving, forming the foundation for higher cognitive processes. Egocentrism (Choice A) refers to a stage in Piaget's theory of cognitive development, not Vygotsky's. Sensorimotor activity (Choice C) is part of Piaget's stages of cognitive development, focusing on how infants understand the world through sensory experiences and physical actions. Self-reflection (Choice D) involves introspection and examination of one's thoughts and feelings, which is not the central concept in Vygotsky's theory.
5. A client with frequent tonic-clonic seizures is being admitted. What action should the nurse add to the client's plan of care?
- A. Ensure blankets are placed on all four sides of the bed.
- B. Refrain from using restraints during seizure activity.
- C. Position the client laterally during seizure activity.
- D. Have a tongue depressor available at the client's bedside.
Correct answer: D
Rationale: The correct action the nurse should add to the client's plan of care is to have a tongue depressor available at the client's bedside. This is important during a seizure to prevent the client from biting their tongue. Placing the client laterally helps maintain a clear airway and prevents aspiration, making choice C a good practice during seizure activity. Using restraints during a seizure can cause injuries and should be avoided, making choice B incorrect. Wrapping blankets around all four sides of the bed is unnecessary for seizure management and does not contribute to the client's safety during a seizure, making choice A incorrect.
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