short bowel syndrome usually occurs when

ATI RN

ATI RN Custom Exams Set 4

1. Short-bowel syndrome usually occurs when:

A. The longitudinal muscles of the intestine contract
B. More than 50% of the small intestine is surgically removed
C. More than 50% of the large intestine is surgically removed
D. Transit time is decreased due to infection or drugs

Correct answer: B

Rationale: Short-bowel syndrome usually occurs when more than 50% of the small intestine is surgically removed. This condition results in malabsorption of nutrients and fluids due to the reduced length of the small intestine. Choice A is incorrect because the contraction of longitudinal muscles does not lead to short-bowel syndrome. Choice C is incorrect as short-bowel syndrome is primarily related to the small intestine, not the large intestine. Choice D is incorrect since decreased transit time due to infection or drugs is not a direct cause of short-bowel syndrome.

2. The unlicensed nursing assistant is applying elastic compression stockings to the client. Which action by the assistant warrants immediate intervention by the nurse?

A. The assistant is putting the stockings on while the client is in the chair.
B. The assistant inserted two (2) fingers under the proximal end of the stocking.
C. The assistant elevated the feet while lying down to put on the stockings.
D. The assistant made sure the toes were warm after putting the stockings on.

Correct answer: A

Rationale: The correct answer is A because compression stockings should be applied while the client is lying down to prevent pooling of blood in the legs, which can occur when the client is sitting or standing. Choice B is not a cause for immediate intervention as inserting two fingers under the proximal end of the stocking helps ensure proper fit. Choice C demonstrates the correct technique of elevating the feet while lying down to put on the stockings. Choice D also shows good care by making sure the toes were warm after putting the stockings on.

3. Which of the following grains is acceptable for someone with celiac disease?

A. Rice
B. Rye
C. Wheat
D. Barley

Correct answer: A

Rationale: The correct answer is A, Rice. Rice is a gluten-free grain and is safe for individuals with celiac disease. Rye, wheat, and barley contain gluten, which can trigger adverse reactions in individuals with celiac disease. Therefore, choices B, C, and D are incorrect for someone with this condition.

4. A client scheduled for surgery cannot sign the operative consent form because he has been sedated with opioid analgesics. The nurse should take which best action regarding the informed consent?

A. Obtain a court order for the surgery
B. Sign the informed consent on behalf of the client
C. Send the client to surgery without the consent form being signed
D. Obtain a telephone consent from a family member, with the consent being witnessed by two healthcare providers

Correct answer: D

Rationale: In situations where a client is unable to sign the consent form, obtaining a telephone consent from a family member, with the consent being witnessed by two healthcare providers, is the best course of action. This ensures that the client's best interests are considered and that proper authorization is obtained. Option A, obtaining a court order, is not necessary in this scenario and could delay the surgery. Option B, signing the consent on behalf of the client, is not appropriate as it may raise ethical and legal concerns. Option C, sending the client to surgery without a signed consent form, is not advisable as it violates the principles of informed consent and places the client at risk.

5. The nurse is caring for clients on a cardiac floor. Which client should the nurse assess first?

A. The client with three (3) unifocal PVCs in a minute
B. The client diagnosed with coronary artery disease who wants to ambulate
C. The client diagnosed with mitral valve prolapse with an audible S3
D. The client diagnosed with pericarditis who is in normal sinus rhythm

Correct answer: C

Rationale: The correct answer is C because an audible S3 in a client with mitral valve prolapse could indicate heart failure and requires immediate assessment. Choice A is not as urgent as an audible S3 in mitral valve prolapse. Choice B, a client with coronary artery disease wanting to ambulate, does not present an immediate concern compared to a potential heart failure indicated by an audible S3. Choice D, a client with pericarditis in normal sinus rhythm, is stable and does not require immediate attention when compared to a potential heart failure situation signified by an audible S3 in mitral valve prolapse.