vasopressin pitressin therapy is prescribed for a client with a diagnosis of bleeding esophageal varices the nurse is preparing to administer the medi

ATI RN

Gastrointestinal System Nursing Exam Questions

1. Vasopressin (Pitressin) therapy is prescribed for a client with a diagnosis of bleeding esophageal varices. The nurse is preparing to administer the medication to the client. Which of the following essential items is needed during the administration of this medication?

A. A cardiac monitor
B. An intubation set
C. A suction setup
D. A tracheotomy set

Correct answer: A

Rationale: The major action of vasopressin is constriction of the splanchnic blood flow. Continuous electrocardiogram and blood pressure monitoring are essential because of the constrictive effects of the medication on the coronary arteries. Options 2, 3, and 4 are not essential items required during the administration of this medication.

2. The client with GERD complains of a chronic cough. The nurse understands that in a client with GERD this symptom may be indicative of which of the following conditions?

A. Development of laryngeal cancer
B. Irritation of the esophagus
C. Esophageal scar tissue formation
D. Aspiration of gastric contents

Correct answer: D

Rationale: Aspiration of gastric contents can lead to a chronic cough in clients with GERD.

3. 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.

4. The nurse has inserted a nasogastric tube to the level of the oropharynx and has repositioned the client’s head in a flexed-forward position. The client has been asked to begin swallowing. The nurse starts slowly to advance the nasogastric tube with each swallow. The client begins to cough, gag, and choke. Which nursing action would least likely result in proper tube insertion and promote client relaxation?

A. Continuing to advance the tube to the desired distance
B. Pulling the tube back slightly
C. Checking the back of the pharynx using a tongue blade and flashlight.
D. Instructing the client to breathe slowly and take sips of water.

Correct answer: A

Rationale: As the nasogastric tube is passed through the oropharynx, the gag reflex is stimulated, which may cause coughing, gagging, or choking. Instead of passing through to the esophagus, the nasogastric tube may coil around itself in the oropharynx, or it may enter the larynx and obstruct the airway, pulling the tube back slightly will remove it from the larynx; advancing the tube might position it in the trachea. Swallowing closes the epiglottis over the trachea and helps move the tube into the esophagus. Slow breathing helps the client relax to reduce the gag response. The nurse should check the back of the client’s throat to note if the tube has coiled. The tube may be advanced after the client relaxes.