ATI RN
NCLEX Questions Gastrointestinal System Questions
Question 1 of 5
An excessive response or activity of T suppressor cells would most likely be associated with
Correct Answer: B
Rationale: The correct answer is B: cancer. T suppressor cells play a crucial role in regulating the immune response to prevent excessive activation, which can lead to the development of cancer. In cancer, T suppressor cells may become dysfunctional, allowing cancer cells to evade immune surveillance and proliferate. Autoimmune diseases (choice A) are more associated with a breakdown in immune tolerance, leading to an overactive immune response against self-antigens. Allergies (choice C) involve an exaggerated immune response to harmless substances, primarily driven by IgE antibodies and other immune cells, rather than T suppressor cells. Graft rejection (choice D) is typically mediated by T helper cells and cytotoxic T cells targeting foreign antigens present in transplanted tissues, rather than T suppressor cells.
Question 2 of 5
The pacemaker signal generated by the SA node spreads to the ventricles by passing through the AV node. What would happen to the contraction of the ventricles if there was a complete block at the AV node?
Correct Answer: C
Rationale: Rationale: A complete block at the AV node would prevent the transmission of the pacemaker signal from the SA node to the ventricles. As a result, the ventricles would not receive the signal to contract at their normal rate. Instead, they would rely on their inherent ability to generate impulses, resulting in a slower, but still rhythmic contraction. This scenario is known as an escape rhythm, where a lower pacemaker takes over in the absence of the SA node signal. Summary: A: the ventricles would cease beating - Incorrect, as the ventricles have their own intrinsic pacemaker. B: the ventricles would beat very fast and uncontrollably - Incorrect, as a complete AV block would lead to a slower rhythm. D: the ventricles would contract at the same rate as the atria - Incorrect, as the ventricles and atria have different intrinsic rates.
Question 3 of 5
You would be most concerned about which client having an order for TPN (total parenteral nutrition) fat emulsion?
Correct Answer: D
Rationale: Correct Answer: D Rationale: 1. TPN fat emulsion can increase the risk of fat embolism in clients with fractures. 2. Fat embolism is a serious complication in clients with long bone fractures, like a fractured femur. 3. Clients with gastrointestinal issues, anorexia nervosa, chronic diarrhea, or vomiting are not at increased risk for fat embolism. 4. Monitoring for signs of fat embolism is crucial in clients receiving TPN fat emulsion to prevent complications.
Question 4 of 5
A client has to undergo a barium enema for a suspected GI disorder. During the test, he experiences a strong urge to defecate and seeks the nurse's advice. Which of the following should the nurse do?
Correct Answer: B
Rationale: The correct answer is B: Assure him that most people can retain the urge. The rationale is as follows: 1. Retaining the urge during a barium enema is common due to the pressure from the barium solution. 2. Advising the client to clear his bowel immediately is incorrect because it may disrupt the test. 3. Giving analgesics to relieve the urge is incorrect as it does not address the issue. 4. Instructing to drink plenty of fluids is incorrect as it does not help in managing the urge. In summary, choice B is correct as it reassures the client and helps maintain the integrity of the test.
Question 5 of 5
A client with ulcerative colitis, who experiences severe diarrhea, is prescribed a cleansing enema to relieve the symptoms. Which of the following interventions should the nurse consider at this stage?
Correct Answer: A
Rationale: The correct answer is A: Question the physician about the use of the cleansing enema. In this scenario, the nurse should question the physician because administering a cleansing enema to a client with ulcerative colitis and severe diarrhea can potentially exacerbate the condition. The nurse needs to verify if the enema is the appropriate intervention and if there are alternative treatments that may be safer and more effective. Summary: - Choice B: Educating the client about the procedure does not address the potential risks of administering the enema. - Choice C: Positioning the client comfortably is important but does not address the appropriateness of the enema. - Choice D: Instructing the client to visit the toilet before the enema does not address the potential risks associated with the procedure.