ATI RN
Gastrointestinal System Nursing Exam Questions Questions
Question 1 of 5
A nurse is inserting a nasogastric tube in an adult client. During the procedure, the client begins to cough and has difficulty breathing. Which of the following is the most appropriate nursing action?
Correct Answer: B
Rationale: The correct answer is B: Pull back on the tube and wait until the respiratory distress subsides. This action allows for the nurse to relieve the pressure on the airway caused by the nasogastric tube, potentially alleviating the client's difficulty in breathing. It is important to prioritize the client's respiratory status and ensure they can breathe comfortably before proceeding with the procedure. A: Removing the tube may worsen the respiratory distress and delay appropriate intervention. C: Quickly inserting the tube can further compromise the client's breathing and cause more distress. D: While notifying the physician is important, immediate intervention to address the breathing difficulty is crucial before seeking further assistance.
Question 2 of 5
The nurse aspirates 40 mL of undigested formula from the client's nasogastric tube. Before administering an intermittent tube feeding, the nurse understands that the 40 mL of gastric aspirate should be
Correct Answer: B
Rationale: The correct answer is B because pouring the 40 mL of gastric aspirate back into the nasogastric tube through a syringe with the plunger removed ensures the undigested formula is returned to the stomach for digestion. This method maintains the balance of electrolytes and nutrients and prevents potential complications. Choice A is incorrect because discarding the aspirate without returning it to the stomach can lead to electrolyte imbalances and nutritional deficiencies. Choice C is incorrect because mixing the aspirate with formula before administering it can cause inaccurate dosing and potential nutrient interactions. Choice D is incorrect because diluting the aspirate with water and forcibly injecting it back into the stomach can cause discomfort and potential complications for the client.
Question 3 of 5
A nurse is preparing to remove a nasogastric tube from a client. The nurse would instruct the client to do which of the following just before the nurse removes the tube?
Correct Answer: B
Rationale: The correct answer is B: To take hold and hold a deep breath. This is because holding a deep breath helps prevent the aspiration of gastric contents when removing the nasogastric tube. By taking a deep breath and holding it, the client creates positive pressure in the lungs, which can help prevent the contents from entering the airway. Rationale for other choices: A: Performing Valsalva's maneuver (straining while holding breath) can increase intra-abdominal pressure and potentially push gastric contents upward, increasing the risk of aspiration. C: Exhaling does not provide the same protection against aspiration as holding a deep breath. D: Inhaling and exhaling quickly does not create the same protective mechanism as holding a deep breath.
Question 4 of 5
The nurse is planning to teach the client with gastroesophageal reflux disease about substances that will increase the lower esophageal sphincter pressure. Which of the following items would the nurse include on this list?
Correct Answer: B
Rationale: The correct answer is B: Nonfat milk. Nonfat milk is alkaline and can help increase lower esophageal sphincter pressure, reducing reflux symptoms. Fatty foods (A) can relax the sphincter and worsen symptoms. Chocolate (C) and coffee (D) are known triggers for reflux and can also decrease sphincter pressure. Therefore, the nurse would include nonfat milk in the teaching to help manage symptoms of gastroesophageal reflux disease.
Question 5 of 5
Lactulose (Chronulac) is prescribed for a client with a diagnosis of hepatic encephalopathy. The nurse would determine that this medication has had a therapeutic effect if which of the following is noted?
Correct Answer: B
Rationale: The correct answer is B: Decreased serum ammonia level. Lactulose is used to treat hepatic encephalopathy by reducing serum ammonia levels through its laxative effect, promoting the excretion of ammonia in the feces. Decreased ammonia levels indicate that the medication is effectively managing the condition. Increased red blood cell count (A), increased protein level (C), and decreased white blood cell level (D) are not directly related to the therapeutic effect of lactulose in hepatic encephalopathy.