ATI RN
ATI Gastrointestinal System
1. The nurse develops a plan of care for a client with a T tube. Which one of the following nursing interventions should be included?
- A. Inspect skin around the T tube daily for irritation.
- B. Irrigate the T tube every 4 hours to maintain patency.
- C. Maintain the client in a supine position while the T tube is in place.
- D. Keep the T tube clamped except during mealtimes.
Correct answer: A
Rationale: The correct nursing intervention to include in the plan of care for a client with a T tube is to inspect the skin around the T tube daily for irritation. Bile is erosive and can cause skin irritation, so it is crucial to keep the skin clean and dry. T tubes are not routinely irrigated; irrigation is done only with a physician's order. It is unnecessary to maintain the client in a supine position; instead, assist the client into a position of comfort. T tubes are not typically clamped unless ordered by a physician, and if clamped, it is usually done 1 to 2 hours before and after meals.
2. Kevin has a history of peptic ulcer disease and vomits coffee-ground emesis. What does this indicate?
- A. He has fresh, active upper GI bleeding.
- B. He needs immediate saline gastric lavage.
- C. His gastric bleeding occurred 2 hours earlier.
- D. He needs a transfusion of packed RBCs.
Correct answer: C
Rationale: Coffee-ground emesis is a sign of upper gastrointestinal bleeding that occurred approximately 2 hours earlier. It results from the breakdown of blood in the stomach due to digestive enzymes, giving it a coffee-ground appearance. Choice A is incorrect because coffee-ground emesis indicates older, partially digested blood, not fresh active bleeding. Choice B is incorrect as gastric lavage is not indicated for coffee-ground emesis. Choice D is incorrect because a transfusion of packed RBCs is not the immediate management for this presentation.
3. Rob is a 46 y.o. admitted to the hospital with a suspected diagnosis of Hepatitis B. He’s jaundiced and reports weakness. Which intervention will you include in his care?
- A. Regular exercise.
- B. A low-protein diet.
- C. Allow patient to select his meals.
- D. Rest period after small, frequent meals.
Correct answer: D
Rationale: For a patient with hepatitis B who is jaundiced and reports weakness, providing rest periods after small, frequent meals is important.
4. A client with rectal cancer may exhibit which of the following symptoms?
- A. Abdominal fullness
- B. Gastric fullness
- C. Rectal bleeding
- D. Right upper quadrant pain
Correct answer: C
Rationale: Rectal bleeding is a common symptom in clients with rectal cancer.
5. Elmer is scheduled for a proctoscopy and has an I.V. The doctor wrote an order for 5mg of I.V. diazepam(Valium). Which order is correct regarding diazepam?
- A. Give diazepam in the I.V. port closest to the vein.
- B. Mix diazepam with 50 ml of dextrose 5% in water and give over 15 minutes.
- C. Give diazepam rapidly I.V. to prevent the bloodstream from diluting the drug mixture.
- D. Question the order because I.V. administration of diazepam is contraindicated.
Correct answer: A
Rationale: The correct method for administering I.V. diazepam is to give it in the I.V. port closest to the vein.
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