ATI RN
Gastrointestinal System Nursing Exam Questions Questions
Question 1 of 5
A nurse is developing a plan of care for a client who will be returning to a nursing unit following a percutaneous transhephatic cholangiogram. The nurse includes which intervention in the postprocedure plan of care?
Correct Answer: A
Rationale: The correct answer is A: Place a sandbag over the insertion site. This intervention helps maintain pressure on the puncture site, reducing the risk of bleeding or hematoma formation post-procedure. Placing a sandbag over the insertion site is a standard practice to ensure hemostasis and prevent complications. Explanation for incorrect choices: B: Allowing bathroom privileges only is unrelated to the specific care needs following a percutaneous transhepatic cholangiogram. C: Encouraging fluid intake is a general nursing intervention and does not directly address the postprocedure care requirements for this specific procedure. D: Allowing the client to sit in a chair for meals is not a priority post-procedure and does not address the potential complications associated with the puncture site.
Question 2 of 5
The nurse has inserted a nasogastric tube to the level of the oropharynx and has repositioned the client's head in a flexed-forward position. The client has been asked to begin swallowing. The nurse starts slowly to advance the nasogastric tube with each swallow. The client begins to cough, gag, and choke. Which nursing action would least likely result in proper tube insertion and promote client relaxation?
Correct Answer: A
Rationale: Correct Answer: A Rationale: 1. The client is experiencing coughing, gagging, and choking, indicating improper tube insertion. 2. Continuing to advance the tube can lead to further discomfort and potential complications. 3. Pulling the tube back slightly allows for reevaluation of placement and prevents further irritation. 4. Checking the back of the pharynx can identify any obstruction or incorrect placement. 5. Instructing the client to breathe slowly and take sips of water can help relax the client and facilitate proper insertion.
Question 3 of 5
A nurse is giving dietary instructions to a client who has a new colostomy. The nurse encourages the client to eat foods representing which of the following diets for the first 4 to 6 weeks postoperatively?
Correct Answer: D
Rationale: The correct answer is D: Low-residue. After colostomy surgery, the bowel needs time to heal. A low-residue diet helps reduce the amount of undigested food passing through the colon, easing digestion and minimizing strain on the stoma. This diet typically includes easily digestible foods like white bread, rice, pasta, and well-cooked vegetables. High-protein (choice A) and high-carbohydrate (choice B) diets can be harder to digest and may cause discomfort. A low-calorie diet (choice C) is not necessary during the initial postoperative period when the focus should be on promoting healing and comfort.
Question 4 of 5
The nurse is preparing to discontinue a client's nasogastric tube. The client is positioned properly, and the tube has been flushed with 15 mL of air to clear secretions. Before removing the tube, the nurse makes which statement to the client?
Correct Answer: C
Rationale: The correct answer is C because instructing the client to take a deep breath and slowly exhale while the tube is being removed helps relax the client's throat muscles, making the removal process smoother and less uncomfortable. Taking a deep breath and holding it (choice D) could lead to increased tension and resistance, while bearing down (choice B) may cause the client to push against the tube, making the removal difficult. Instructing the client to breathe normally (choice A) doesn't provide specific guidance on how to facilitate the removal process.
Question 5 of 5
The client with a colostomy has an order for irrigation of the colostomy. The nurse uses which solution for the irrigation?
Correct Answer: B
Rationale: The correct answer is B: Tap water. Tap water is used for colostomy irrigation as it is isotonic and won't disrupt electrolyte balance. Distilled water (A) can cause electrolyte imbalances. Sterile water (C) may not be necessary, and Lactated Ringer's (D) is not typically used for colostomy irrigation.