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. The nurse evaluates the client’s stoma during the initial post-op period. Which of the following observations should be reported immediately to the physician?
- A. The stoma is slightly edematous
- B. The stoma is dark red to purple
- C. The stoma oozes a small amount of blood
- D. The stoma does not expel stool
Correct answer: B
Rationale: A dark red to purple stoma may indicate compromised blood flow or ischemia, which requires immediate medical attention. This color change could be a sign of inadequate blood supply to the stoma tissue, leading to tissue damage or necrosis. Reporting this observation promptly is crucial to prevent further complications. Choices A, C, and D are not indicative of immediate medical concern. A slightly edematous stoma, oozing a small amount of blood, or not expelling stool may not be uncommon findings during the initial post-op period and can be managed without urgent intervention.
3. The student nurse is preparing a teaching care plan to help improve nutrition in a patient with achalasia. You include which of the following:
- A. Swallow foods while leaning forward.
- B. Omit fluids at mealtimes.
- C. Eat meals sitting upright.
- D. Avoid soft and semisoft foods.
Correct answer: C
Rationale: Eating meals while sitting upright helps improve swallowing and prevent complications in patients with achalasia.
4. Which of the following nursing measures would be inappropriate when caring for a client with a Cantor tube?
- A. Injecting 10 mL of air into the tube to facilitate drainage.
- B. Applying a water-soluble lubricant to the client's nares.
- C. Coiling extra tubing on the client's bed.
- D. Irrigating the tube with 50 mL of normal saline solution.
Correct answer: D
Rationale: Intestinal tubes are not irrigated. Injecting air into the tube, applying water-soluble lubricant, and coiling extra tubing are appropriate nursing measures.
5. Brenda, a 36 y.o. patient is on your floor with acute pancreatitis. Treatment for her includes:
- A. Continuous peritoneal lavage.
- B. Regular diet with increased fat.
- C. Nutritional support with TPN.
- D. Insertion of a T tube to drain the pancreas.
Correct answer: C
Rationale: Treatment for acute pancreatitis includes nutritional support with TPN.
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