ATI RN
ATI Gastrointestinal System
1. Which of the following factors should be the main focus of nursing management for a client hospitalized for cholecystitis?
- A. Administration of antibiotics
- B. Assessment for complications
- C. Preparation for lithotripsy
- D. Preparation for surgery
Correct answer: B
Rationale: Assessment for complications should be the main focus of nursing management for a client hospitalized for cholecystitis.
2. Children may believe that they are responsible for their parents' divorce and interpret the separation as punishment. At which age is this most likely to occur?
- A. 1 year
- B. 4 years
- C. 8 years
- D. 13 years
Correct answer: C
Rationale: At around 8 years old, children may feel they are responsible for their parents' divorce and view it as a punishment, which can impact their emotional well-being.
3. A nurse is planning to administer a blood transfusion to a client. Which of the following should the nurse do to prevent an adverse transfusion reaction?
- A. Verify the client's blood type with the provider's prescription
- B. Ensure the client's consent for the transfusion is on file
- C. Administer a diuretic prior to starting the transfusion
- D. Check the client's temperature prior to the transfusion
Correct answer: A
Rationale: The correct answer is to verify the client's blood type with the provider's prescription. This is crucial to prevent an adverse transfusion reaction due to incompatibility. Ensuring the blood type matches before starting the transfusion is a standard safety practice. Option B, ensuring client consent, is important but not directly related to preventing a transfusion reaction. Option C, administering a diuretic, is unnecessary and can be harmful in this context. Option D, checking the client's temperature, is important for general assessment but not specifically focused on preventing a transfusion reaction.
4. A nurse is caring for a client who has an indwelling urinary catheter. Which of the following interventions should the nurse implement to prevent catheter-associated infections?
- A. Change the catheter every 24 hours
- B. Ensure the drainage bag is positioned above the bladder
- C. Perform routine irrigation of the catheter
- D. Empty the drainage bag every 4 hours
Correct answer: B
Rationale: The correct answer is to ensure the drainage bag is positioned above the bladder. This positioning prevents urine reflux into the bladder, reducing the risk of catheter-associated infections. Changing the catheter too frequently (Choice A) can actually increase the risk of infection by introducing pathogens. Performing routine catheter irrigation (Choice C) is no longer recommended as it can increase the risk of infection by introducing bacteria. Emptying the drainage bag every 4 hours (Choice D) is a standard practice to prevent urinary stasis but is not directly related to preventing catheter-associated infections.
5. When should the nurse initiate discharge planning for a client experiencing an exacerbation of heart failure?
- A. During the admission process
- B. As soon as the client's condition is stable
- C. After consulting with the client's family
- D. During the initial team conference
Correct answer: B
Rationale: The correct time for the nurse to initiate discharge planning for a client experiencing an exacerbation of heart failure is as soon as the client's condition is stable. Discharge planning should begin early to ensure a smooth transition and continuity of care. While involving the client's family in the planning process is crucial, the primary focus should be on starting the preparations for discharge once the client's immediate health concerns are addressed and their condition is stable. Waiting for a team conference or after consulting with the family may delay the planning process, which is not ideal in ensuring a timely and effective discharge plan.
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