ATI RN
Gastrointestinal System Nursing Exam Questions Questions
Question 1 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 2 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.
Question 3 of 5
A nurse has been caring for a client with a Sengstaken-Blakemore tube. The physician arrives on the nursing unit and deflates the esophageal balloon. The nurse should monitor the client most closely for which of the following?
Correct Answer: C
Rationale: The correct answer is C: Vomiting blood. When the esophageal balloon of the Sengstaken-Blakemore tube is deflated, the risk of esophageal variceal bleeding increases. Vomiting blood indicates active bleeding and requires immediate intervention. Swelling of the abdomen (A) is not directly related to deflating the balloon. Bloody diarrhea (B) is not a common complication of deflating the balloon. An elevated temperature and a rise in blood pressure (D) are not typical signs of complications related to the deflation of the esophageal balloon.
Question 4 of 5
A client is scheduled for an abdominal perineal resection with permanent colostomy. Which of the following measures would most likely be included in the plan for the client's preoperative preparation?
Correct Answer: B
Rationale: The correct answer is B: Administer kanamycin (Kantrex) the night before surgery. This antibiotic is typically given preoperatively to reduce the risk of infection during the surgical procedure. It helps to eliminate or reduce the number of bacteria in the gastrointestinal tract, which could potentially contaminate the surgical site during the abdominal perineal resection with permanent colostomy. A: Keeping the client NPO for 2 days before surgery is not necessary for this procedure and could lead to unnecessary dehydration and discomfort. C: Informing the client that chest tubes will be in place after surgery is not directly related to preoperative preparation for this specific surgery. D: Advising the client to limit activity is important for postoperative recovery, but it is not a preoperative measure specific to this surgery.
Question 5 of 5
The client with chronic pancreatitis needs information on dietary modification to manage the health problem. The nurse teaches the client to limit which of the following items in the diet?
Correct Answer: C
Rationale: The correct answer is C: Fat. In chronic pancreatitis, the pancreas struggles to produce digestive enzymes, leading to poor fat digestion. Limiting fat intake can help reduce symptoms like abdominal pain and diarrhea. Carbohydrates and proteins are essential for energy and tissue repair, so limiting them is not ideal. Water-soluble vitamins are generally well-absorbed and do not require restriction in chronic pancreatitis.