the nurse is preparing to discontinue a clients nasogastric tube the client is positioned properly and the tube has been flushed with 15 ml of air to
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Nursing Elites

ATI RN

Gastrointestinal System Nursing Exam Questions

1. The nurse is preparing to discontinue a client’s nasogastric tube. The client is positioned properly, and the tube has been flushed with 15 mL of air to clear secretions. Before removing the tube, the nurse makes which statement to the client?

Correct answer: C

Rationale: The client should take a deep breath because the client’s airway will be obstructed temporarily during tube removal. The nurse then tells the client to exhale slowly and withdraws the tube during exhalation. Bearing down could inhibit the removal of the tube. Breathing normally could result in aspiration of gastric secretions during inhalation. Holding the breath does not facilitate tube removal.

2. A nurse has been caring for a client with a Sengstaken-Blakemore tube. The physician arrives on the nursing unit and deflates the esophageal balloon. The nurse should monitor the client most closely for which of the following?

Correct answer: C

Rationale: A Sengstaken-Blakemore tube is inserted into a client with a diagnosis of cirrhosis and ruptured esophageal varices. The tube has an esophageal and a gastric balloon. The esophageal balloon exerts pressure on the bleeding. The pressure of the esophageal balloon is released at intervals to decrease the risk of trauma to esophageal tissues, including esophageal rupture or necrosis. When the balloon is deflated the client may begin to bleed again from the esophageal varices, noted by vomiting of blood.

3. Dark, tarry stools indicate bleeding in which location of the GI tract?

Correct answer: C

Rationale: Dark, tarry stools indicate bleeding in the upper GI tract.

4. Sharon has cirrhosis of the liver and develops ascites. What intervention is necessary to decrease the excessive accumulation of serous fluid in her peritoneal cavity?

Correct answer: A

Rationale: Restricting fluids is necessary to decrease the excessive accumulation of serous fluid in the peritoneal cavity for a patient with ascites due to cirrhosis.

5. The nurse instructs the nursing assistant on how to provide oral hygiene for a client who cannot perform this task for himself. Which of the following techniques should the nurse tell the assistant to incorporate into the client’s daily care?

Correct answer: C

Rationale: Swabbing the client’s tongue, gums, and lips with a soft foam applicator every 2 hours helps maintain oral hygiene for a client who cannot perform this task.

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