ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 44 : Introduction to the Gastrointestinal System and Accessory Structures Questions
Question 1 of 5
The nurse is caring for a client experiencing diarrhea. When teaching about the site in the body where water and electrolytes are absorbed, the nurse is most correct to instruct on which location?
Correct Answer: C
Rationale: The nurse is correct in instructing the client that water and electrolytes are mainly absorbed in the large intestine. The other options are not the best site for absorption.
Question 2 of 5
The nurse is providing care to a client who has had a percutaneous liver biopsy. For what would the nurse monitor the client?
Correct Answer: A
Rationale: A major complication after a liver biopsy is bleeding, so it would be important for the nurse to monitor the client for signs and symptoms of bleeding. Return of the gag reflex would be important for the client who had an esophagogastroduodenoscopy to prevent aspiration. Monitoring the passage of stool would be important for a client who had a barium enema or colonoscopy. Monitoring intake and output is a general measure indicated for any client. It is not specific to a liver biopsy.
Question 3 of 5
The nurse is assessing a client of color for jaundice. In which location(s) would the nurse assess for discoloration? Select all that apply.
Correct Answer: A,B,E,F
Rationale: In very dark-skinned clients, the nurse inspects the hard palate, gums, conjunctiva, and surrounding tissues for discoloration. If the skin appears jaundiced, the nurse inspects the sclera if it is yellow.
Question 4 of 5
The nurse is caring for a geriatric client at a long-term care facility. When administering the client's medications, which age-related change(s) of the client is anticipated? Select all that apply.
Correct Answer: B,C,E
Rationale: Age-related considerations when administering medications to a geriatric client include administering medications slowly and allowing time between medications due to a decreased motility in the esophagus. Additionally, the client has a weakened gag reflex, which may cause the client to choke. The client has a decreased elasticity of the rectal wall potentially causing fecal incontinence. Geriatric clients have a decrease in saliva production requiring water with oral medication administration. There is also a decrease in the amount of gastric secretions, which could produce nausea.
Question 5 of 5
The nurse is reviewing the results of a Hemoccult test with the client. Which question(s) asked by the nurse is important in screening for the potential of a false-positive result? Select all that apply.
Correct Answer: C,D,E
Rationale: When obtaining a positive Hemoccult test, the client needs to be screened for a false-positive test result. Substances that may cause a false-positive include red meat, aspirin, and excessive alcohol. Screening for the frequency and amount of these are important. False-negative results are screened in individuals who ingest ascorbic acid and iron supplements.