ATI RN
ATI Gastrointestinal System
1. While caring for a client with peptic ulcer disease, the client reports that he has been nauseated most of the day and is now feeling lightheaded and dizzy. Based upon these findings, which nursing actions would be most appropriate for the nurse to take? Select all that apply.
- A. Administering an antacid hourly until nausea subsides.
- B. Monitoring the client’s vital signs
- C. Notifying the physician of the client’s symptoms
- D. Initiating oxygen therapy
Correct answer: 2, 3
Rationale: Monitoring the client's vital signs and notifying the physician of the client's symptoms are crucial actions based on the reported symptoms.
2. A nurse is caring for a client who has a new prescription for metformin. Which of the following findings in the client's medical history should the nurse report to the provider?
- A. History of hypertension
- B. History of polycystic ovary syndrome
- C. History of asthma
- D. History of kidney disease
Correct answer: D
Rationale: The correct answer is D, history of kidney disease. Metformin should be used with caution in clients with kidney disease due to the risk of lactic acidosis, a serious complication. Reporting this finding to the provider is crucial for assessing the appropriateness of continuing metformin therapy. Choices A, B, and C do not contraindicate the use of metformin, so they are not the priority for reporting.
3. In a breech presentation, how is the infant positioned for delivery?
- A. Is too large to be delivered vaginally.
- B. Is delivered feet or bottom first.
- C. Is delivered head first.
- D. Appears face down.
Correct answer: B
Rationale: In a breech presentation, the infant is positioned to be delivered feet or bottom first. This is because the baby's pelvis or feet enter the birth canal before the head. Therefore, choice B is correct. Choices A, C, and D are incorrect because a breech presentation specifically refers to the baby being positioned feet or bottom first, not head first, face down, or being too large for vaginal delivery.
4. A nurse is caring for a client who has just returned from the operating room following the creation of a colostomy. The nurse is assessing the drainage in the pouch attached to the site where the colostomy was formed and notes serosanguineous drainage. Which nursing action is most appropriate based on this assessment?
- A. Notify the physician
- B. Document the amount and characteristics of the drainage
- C. Apply ice to the stoma site
- D. Apply pressure to the site
Correct answer: B
Rationale: During the first 24 to 72 hours following surgery, mucus and serosanguineous drainage are expected from the stoma. Documenting the amount and characteristics of the drainage is appropriate. The nurse does not need to notify the physician because this is an expected finding. Applying ice or pressure to the site is not necessary.
5. When a client is comatose and has advance directives stating a desire to avoid life-sustaining measures, but the family wants these measures, what action should the nurse take?
- A. Arrange for an ethics committee meeting to address the family's concerns.
- B. Support the family's decision and initiate life-sustaining measures.
- C. Complete an incident report.
- D. Encourage the family to contact an attorney.
Correct answer: Arrange for an ethics committee meeting to address the family's concerns.
Rationale: In this scenario, the nurse should prioritize the client's wishes as outlined in the advance directives. By arranging for an ethics committee meeting, the nurse can facilitate discussions between the family and healthcare team to ensure that the client's wishes are respected while addressing the concerns of the family. This approach promotes ethical decision-making and collaborative communication among all involved parties, ultimately aiming to provide the best possible care for the client while considering their autonomy and preferences.
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