ATI RN
ATI Gastrointestinal System Test
1. You’re caring for Betty with liver cirrhosis. Which of the following assessment findings leads you to suspect hepatic encephalopathy in her?
- A. Asterixis
- B. Chvostek’s sign
- C. Trousseau’s sign
- D. Hepatojugular reflex
Correct answer: A
Rationale: Asterixis, a flapping tremor of the hands, is a sign of hepatic encephalopathy.
2. The nurse is performing a colostomy irrigation on a client. During the irrigation, a client begins to complain of abdominal cramps. Which of the following is the most appropriate nursing action?
- A. Notify the physician
- B. Increase the height of the irrigation
- C. Stop the irrigation temporarily.
- D. Medicate with dilaudid and resume the irrigation
Correct answer: C
Rationale: If a client experiences abdominal cramps during a colostomy irrigation, it is appropriate to stop the irrigation temporarily to allow the cramps to subside.
3. A nurse orientee is preparing to insert a nasogastric tube, and a nurse educator is observing the procedure. Which of the following supplies if obtained by the nurse orientee would indicate a need for further education regarding this procedure?
- A. Half-inch or one-inch tape
- B. Oil-soluble lubricant
- C. A glass of tap water with a straw
- D. A 50-mL catheter tip syringe
Correct answer: B
Rationale: Water-soluble lubricant is used to lubricate 3 to 4 inches of the tube at the insertion end. An oil lubricant is not used because if the tube accidentally goes into the bronchus, pneumonia can develop. Half-inch tape is used to secure the tube after the correct placement is verified. A 50-mL catheter tip syringe is used to aspirate gastric contents to confirm placement. The client will be asked to take a sip of water through a straw to help with the passage of the tube.
4. A client is admitted to the hospital after vomiting bright red blood and is diagnosed with a bleeding duodenal ulcer. The client develops a sudden, sharp pain in the midepigastric area along with a rigid, boardlike abdomen. These clinical manifestations most likely indicate which of the following?
- A. An intestinal obstruction has developed
- B. Additional ulcers have developed
- C. The esophagus has become inflamed
- D. The ulcer has perforated
Correct answer: D
Rationale: A sudden, sharp pain in the midepigastric area along with a rigid, boardlike abdomen indicates that the ulcer has perforated.
5. A client with a peptic ulcer is scheduled for a vagotomy. The client asks the nurse about the purpose of this procedure. The nurse tells the client that the procedure:
- A. Decreases food absorption in the stomach
- B. Heals the gastric mucosa
- C. Halts stress reactions
- D. Reduces the stimulus to acid secretions
Correct answer: D
Rationale: A vagotomy reduces the stimulus to acid secretions by cutting the vagus nerve, which innervates the stomach.
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