ATI RN
ATI Gastrointestinal System Quizlet
1. The nurse instructs the ileostomy client to do which of the following as a part of essential care of the stoma?
- A. Cleanse the peristomal skin meticulously
- B. Take in high-fiber foods such as nuts
- C. Massage the area below the stoma
- D. Limit fluid intake to prevent diarrhea.
Correct answer: A
Rationale: Cleansing the peristomal skin meticulously is crucial to prevent irritation and infection around the stoma.
2. A nurse is preparing for the hospital admission of a client who is suspected to have active tuberculosis (TB). Which of the following precautions should the nurse plan to implement to safely care for this client?
- A. Staff and visitors should wear gowns, masks, and gloves while in the client's room.
- B. The client should be placed in a private room with a special ventilation system.
- C. The client may be placed in a room with other clients who require droplet isolation precautions.
- D. The protocol for donning and removing personal protective equipment before entering or leaving the room of a client with TB is different than for clients who are in other types of isolation.
Correct answer: The client should be placed in a private room with a special ventilation system.
Rationale: When caring for a client suspected of having active tuberculosis (TB), it is essential to place the client in a private room with a special ventilation system to prevent the spread of TB bacteria to others. Choice A is incorrect because staff and visitors should wear respiratory protection, not just gowns, masks, and gloves. Choice C is incorrect as clients with TB should not be placed in a room with other clients, as they need to be isolated to prevent transmission. Choice D is incorrect because the protocol for donning and removing personal protective equipment for clients with TB is similar to other types of isolation, focusing on proper infection control measures.
3. A group of prison inmates developed tuberculosis following exposure to an infected inmate. On examination, tissues were soft and granular (like clumped cheese). Which of the following is the most likely cause?
- A. Coagulative necrosis
- B. Liquefactive necrosis
- C. Caseous necrosis
- D. Autonecrosis
Correct answer: C
Rationale: The correct answer is C. Caseous necrosis is characteristic of tuberculosis, where the tissue has a soft, cheese-like appearance. Coagulative necrosis involves protein denaturation, liquefactive necrosis is seen in brain infarcts and abscesses, and autonecrosis is not a recognized term in pathology, making them incorrect choices in this scenario.
4. A client in end-stage osteoporosis is reporting severe pain, with a respiratory rate of 14 per minute. Which of the following medications should the nurse expect to be the highest priority to administer to the client?
- A. Promethazine
- B. Hydromorphone
- C. Ketorolac
- D. Amitriptyline
Correct answer: B
Rationale: In a client with severe pain like the one described, the priority medication to administer is a potent analgesic like hydromorphone. Hydromorphone is a strong opioid pain medication that can effectively manage severe pain. Promethazine (Choice A) is an antiemetic and antihistamine, not a pain medication. Ketorolac (Choice C) is a nonsteroidal anti-inflammatory drug (NSAID) that is contraindicated in end-stage renal disease due to its potential to cause kidney damage. Amitriptyline (Choice D) is a tricyclic antidepressant used for conditions like depression and neuropathic pain, but it is not the first-line treatment for severe acute pain.
5. A client with heart failure is receiving instructions about laxative use. The client should be advised to avoid which of the following laxatives?
- A. Sodium phosphate
- B. Psyllium
- C. Bisacodyl
- D. Polyethylene glycol
Correct answer: A
Rationale: Clients with heart failure often have sodium restrictions. Sodium phosphate can lead to fluid retention due to sodium absorption, which is harmful for individuals with heart failure. Therefore, it should be avoided in this population to prevent exacerbating fluid overload. Psyllium, Bisacodyl, and Polyethylene glycol are safer options for individuals with heart failure as they do not pose the risk of exacerbating fluid overload through sodium retention.
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