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. Which of the following symptoms best describes Murphy’s sign?
- A. Periumbilical ecchymosis exists
- B. On deep palpation and release, pain is elicited
- C. On deep inspiration, pain is elicited and breathing stops
- D. Abdominal muscles are tightened in anticipation of palpation
Correct answer: C
Rationale: Murphy's sign is described as pain elicited on deep inspiration when the examiner's fingers are placed under the right costal margin.
3. A client with gastric cancer may exhibit which of the following symptoms?
- A. Abdominal cramping
- B. Constant hunger
- C. Feeling of fullness
- D. Weight gain
Correct answer: C
Rationale: Clients with gastric cancer may experience a feeling of fullness due to the presence of the tumor.
4. When counseling a client in ways to prevent cholecystitis, which of the following guidelines is most important?
- A. Eat a low-protein diet
- B. Eat a low-fat, low-cholesterol diet
- C. Limit exercise to 10 minutes/day
- D. Keep weight proportionate to height
Correct answer: B
Rationale: Eating a low-fat, low-cholesterol diet is most important for preventing cholecystitis.
5. Which of the following symptoms is a client with colon cancer most likely to exhibit?
- A. A change in appetite
- B. A change in bowel habits
- C. An increase in body weight
- D. An increase in body temperature
Correct answer: B
Rationale: A change in bowel habits is the most common symptom of colon cancer.
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