ATI RN
ATI Gastrointestinal System
1. The nurse is caring for a client following a Billroth II procedure. On review of the post-operative orders, which of the following, if prescribed, would the nurse question and verify?
- A. Irrigating the nasogastric tube
- B. Coughing a deep breathing exercises
- C. Leg exercises
- D. Early ambulation
Correct answer: A
Rationale: Irrigating the nasogastric tube is typically not recommended after a Billroth II procedure unless specifically ordered by a physician due to the risk of disrupting the surgical site.
2. Medical management of the client with diverticulitis should include which of the following treatments?
- A. Reduced fluid intake
- B. Increased fiber in diet
- C. Administration of antibiotics
- D. Exercises to increase intra-abdominal pressure
Correct answer: C
Rationale: Medical management of diverticulitis typically includes the administration of antibiotics to treat infection and inflammation.
3. A client is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should be taken?
- A. Ask the client to consider a direct donation
- B. Withhold the blood transfusion
- C. Ask the client to consider a direct donation
- D. Request a consultation with the ethics committee
Correct answer: A
Rationale: In this situation, the nurse should ask the client to consider a direct donation. This option respects the client's autonomy by exploring alternative options that align with the client's beliefs. Withholding the blood transfusion (choice B) goes against the client's wishes and autonomy. Requesting a consultation with the ethics committee (choice D) should be considered if there is a disagreement that cannot be resolved at the bedside, but it is not the initial step. Choice C is a duplicate of choice A and does not provide a different or additional action to address the situation.
4. A client is prescribed gentamicin for an infection. Which finding indicates a potential adverse reaction to the medication?
- A. Blood pressure 160/90 mm Hg
- B. Presence of red blood cells in the urine
- C. Urine output of 35 mL/hr
- D. Respiratory rate of 22/min
Correct answer: B
Rationale: The presence of red blood cells in the urine is a significant finding that can indicate nephrotoxicity, a potential adverse effect of gentamicin. Nephrotoxicity can lead to kidney damage, and monitoring for this adverse reaction is crucial during gentamicin therapy. Elevated blood pressure (Choice A) is not typically associated with gentamicin adverse reactions. Decreased urine output (Choice C) may suggest kidney impairment but is not as specific as the presence of red blood cells in the urine. Respiratory rate (Choice D) is not directly related to potential adverse reactions to gentamicin.
5. The client with peripheral vascular disease is being taught by the nurse. Which interventions should the nurse discuss with the client?
- A. Keep the area between the toes dry.
- B. Wear comfortable, well-fitting shoes.
- C. Cut toenails straight across.
- D. A, B
Correct answer: D
Rationale: The correct interventions for a client with peripheral vascular disease include keeping the area between the toes dry and wearing comfortable, well-fitting shoes. Choice A is correct as moisture between the toes can lead to skin breakdown and infection. Choice B is also correct as proper footwear helps prevent injury and promotes circulation. Choice C, cutting toenails straight across, is incorrect for peripheral vascular disease clients as cutting them in an arch can reduce the risk of ingrown toenails, which is important for clients with diabetes to prevent complications. Therefore, choices A and B are the most appropriate interventions for the client with peripheral vascular disease.
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