ATI RN
ATI Gastrointestinal System Test
1. You have to teach ostomy self care to a patient with a colostomy. You tell the patient to measure and cut the wafer:
- A. To the exact size of the stoma.
- B. About 1/16” larger than the stoma.
- C. About 1/8” larger than the stoma.
- D. About 1/4″ larger than the stoma.
Correct answer: C
Rationale: The wafer should be measured and cut about 1/8” larger than the stoma to ensure proper fit and prevent skin irritation.
2. A patient presents with a sudden onset of severe chest pain radiating to his back. His blood pressure is significantly higher in the right arm than in the left arm. Which of the following conditions is most likely?
- A. Acute myocardial infarction
- B. Pulmonary embolism
- C. Aortic dissection
- D. Pericarditis
Correct answer: C
Rationale: The correct answer is C, aortic dissection. Aortic dissection is characterized by sudden, severe chest pain that can radiate to the back. The discrepancy in blood pressure between the arms (higher in the right arm) is known as a 'pulse deficit' and is a classic finding in aortic dissection. This condition involves a tear in the inner layer of the aorta, leading to the abnormal flow of blood within the aortic wall. Acute myocardial infarction (choice A) presents with chest pain but typically does not cause discrepancies in blood pressure between arms. Pulmonary embolism (choice B) usually presents with chest pain and difficulty breathing but does not cause unequal blood pressures in the arms. Pericarditis (choice D) can cause chest pain exacerbated by breathing or lying down, but it does not typically lead to differences in blood pressure between arms.
3. When caring for a client's tracheostomy at home, which instruction should the nurse include in the teaching?
- A. Clean with alcohol
- B. Cover the tracheostomy when outside
- C. Replace the tube weekly
- D. Use tap water to clean
Correct answer: B
Rationale: Covering the tracheostomy when outside is crucial as it helps prevent dust and other irritants from entering the airway, reducing the risk of complications. Cleaning with alcohol (choice A) can be too harsh for the skin around the tracheostomy site. While replacing the tube weekly (choice C) is important, it is typically done by healthcare providers. Using tap water to clean (choice D) is not recommended as it may introduce contaminants to the tracheostomy site.
4. A patient with GERD is being taught by a nurse. What should the patient avoid?
- A. Avoid mint and pepper
- B. Increase water intake during meals
- C. Eat frequent small meals
- D. Consume more spicy foods
Correct answer: A
Rationale: Patients with GERD should avoid mint and spicy foods as they can trigger reflux. Choice B ('Increase water intake during meals') is not recommended for GERD patients as it can worsen symptoms by distending the stomach. Choice C ('Eat frequent small meals') is beneficial for GERD patients to prevent excessive stomach distension. Choice D ('Consume more spicy foods') is incorrect as spicy foods can exacerbate GERD symptoms.
5. Which of the following nursing interventions should be implemented to manage a client with appendicitis?
- A. Assessing for pain
- B. Encouraging oral intake of clear fluids
- C. Providing discharge teaching
- D. Assessing for symptoms of peritonitis
Correct answer: D
Rationale: The correct answer is D: Assessing for symptoms of peritonitis. This intervention is crucial in managing a client with appendicitis because it indicates a possible rupture of the inflamed appendix. Symptoms of peritonitis include severe abdominal pain, fever, nausea, vomiting, and abdominal rigidity. Prompt recognition of these symptoms is essential for timely intervention and surgical management. Choices A, B, and C are incorrect because while assessing for pain is important, assessing for symptoms of peritonitis takes precedence due to the critical nature of appendicitis. Encouraging oral intake of clear fluids and providing discharge teaching are not immediate priorities in the management of a client with acute appendicitis.
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