ATI RN
ATI Gastrointestinal System
1. The client being treated for esophageal varices has a Sengstaken-Blakemore tube inserted to control the bleeding. The most important assessment is for the nurse to:
- A. Check that the hemostat is on the bedside
- B. Monitor IV fluids for the shift
- C. Regularly assess respiratory status
- D. Check that the balloon is deflated on a regular basis
Correct answer: C
Rationale: Regularly assessing respiratory status is crucial when a Sengstaken-Blakemore tube is inserted to control bleeding in esophageal varices.
2. The client on furosemide (Lasix) is at risk for which electrolyte imbalance?
- A. Hyperkalemia
- B. Hypokalemia
- C. Hyponatremia
- D. Hypernatremia
Correct answer: B
Rationale: The correct answer is B: Hypokalemia. Furosemide is a loop diuretic that can lead to potassium loss, resulting in hypokalemia. This electrolyte imbalance is a significant risk associated with diuretic use. Choices A, C, and D are incorrect. Hyperkalemia (choice A) is not typically associated with furosemide use. Hyponatremia (choice C) and hypernatremia (choice D) are related to sodium levels, not potassium levels affected by furosemide.
3. Dietary fiber has been recommended for its possible benefits in reducing heart disease by lowering blood cholesterol. How is fiber thought to play its role in lowering blood cholesterol?
- A. Insoluble fiber binds with cholesterol in the large intestine and is excreted in feces
- B. Viscous fiber binds with bile in the intestine and is excreted in feces
- C. Soluble fiber binds with cholesterol in the blood and is excreted by the liver
- D. Insoluble fiber converts to bile in the large intestine and binds with cholesterol
Correct answer: B
Rationale: The correct answer is B. Viscous (soluble) fiber binds with bile acids in the intestine, which are then excreted. The liver must use cholesterol to make more bile acids, thereby lowering blood cholesterol levels. Choice A is incorrect as insoluble fiber does not bind with cholesterol in the large intestine. Choice C is incorrect as soluble fiber does not directly bind with cholesterol in the blood. Choice D is incorrect as insoluble fiber does not convert to bile in the large intestine to bind with cholesterol.
4. A nurse is providing discharge teaching to a client who has had a stroke. Which of the following instructions should the nurse include?
- A. Avoid taking anticoagulant medication.
- B. Limit fluid intake to 1,000 mL per day.
- C. Avoid isometric exercises during recovery.
- D. Perform range-of-motion exercises daily.
Correct answer: D
Rationale: The correct answer is D: Perform range-of-motion exercises daily. After a stroke, performing range-of-motion exercises can help prevent complications such as joint stiffness and contractures. Options A, B, and C are incorrect. Anticoagulant medications are often prescribed to prevent blood clots after a stroke, fluid intake should be adequate unless indicated otherwise, and isometric exercises can be beneficial during recovery.
5. She instructed the interviewees not to tell the interviewees that the data gathered are for her own research project for publication. This teacher has violated the student’s right to:
- A. Not be harmed
- B. Disclosure
- C. Privacy
- D. Self-determination
Correct answer: D
Rationale: Understanding the underlying pathology and therapeutic techniques ensures that nursing care is not only reactive but also preventative, reducing the risk of complications.
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