ATI RN
ATI Gastrointestinal System
1. The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750ml of green-brown drainage. Which nursing intervention is most appropriate?
- A. Notify the physician
- B. Document the findings
- C. Irrigate the T-tube
- D. Clamp the T-tube
Correct answer: B
Rationale: Documenting the findings is the most appropriate action as 750ml of green-brown drainage is expected after a cholecystectomy.
2. When educating a client about to undergo a pacemaker insertion, the nurse explains the normal phases of cardiac muscle tissue. During the repolarization phase, the nurse will stress that membranes must be repolarized before they can be re-excited. Within the cell, the nurse understands that:
- A. Potassium channels open while sodium channels close, causing repolarization to the resting state.
- B. The influx of calcium is the primary stimulus for the repolarization of cardiac tissue.
- C. Only the electrical activity within the heart will determine when repolarization occurs.
- D. The cell membranes need to stay calm, resulting in muscle tissue becoming refractory.
Correct answer: A
Rationale: During the repolarization phase of cardiac muscle tissue, potassium channels open while sodium channels close. This process is crucial for the cardiac muscle to return to its resting state after depolarization. Potassium moving out of the cell and sodium staying out helps reset the membrane potential and prepare the cell for the next depolarization phase. The influx of calcium is not the primary stimulus for repolarization in cardiac tissue; it is mainly involved in the depolarization phase. While electrical activity within the heart influences repolarization, the specific ion movements described in choice A are what physiologically drive repolarization. Cell membranes need to be in an active state during repolarization, not calm, to facilitate the necessary ion movements for muscle tissue to properly function.
3. A school-age child has peripheral edema. Which of the following assessments should the nurse perform to confirm peripheral edema?
- A. Palpate the dorsum of the child's feet
- B. Weigh the child daily using the same scale
- C. Assess the child's skin turgor
- D. Observe the child for periorbital swelling
Correct answer: A
Rationale: To confirm peripheral edema in a child, the nurse should palpate the dorsum of the child's feet by pressing a fingertip against a bony prominence for 5 seconds. This assessment helps detect the presence of pitting edema, which is characterized by an indentation that remains after the pressure is released.
4. What is a common challenge in community health nursing?
- A. Limited resources
- B. High patient caseloads
- C. Cultural barriers
- D. Changing health behaviors
Correct answer: A
Rationale: Limited resources are a common challenge in community health nursing as they can impact the ability to deliver comprehensive care. This challenge can include financial constraints, lack of supplies, and inadequate staffing levels, all of which can hinder the provision of effective healthcare services to the community.
5. Which of the following disorders is more likely to be associated with blood in the stool?
- A. Gastroesophageal reflux
- B. Crohn's disease
- C. Irritable bowel syndrome
- D. Colon cancer
Correct answer: D
Rationale: The correct answer is D, Colon cancer. Colon cancer commonly presents with blood in the stool due to bleeding from the tumor. Gastroesophageal reflux (Choice A) is associated with heartburn and regurgitation of stomach contents into the esophagus. Crohn's disease (Choice B) is a type of inflammatory bowel disease that can cause symptoms like abdominal pain, diarrhea, and weight loss, but it does not typically present with blood in the stool as a primary symptom. Irritable bowel syndrome (Choice C) is a functional gastrointestinal disorder characterized by symptoms such as abdominal pain, bloating, and changes in bowel habits, but it does not usually involve blood in the stool as a prominent feature.
Similar Questions
Access More Features
ATI Basic
- 50,000 Questions with answers
- All ATI courses Coverage
- 30 days access @ $69.99
ATI Basic
- 50,000 Questions with answers
- All ATI courses Coverage
- 90 days access @ $149.99