ATI RN
ATI Gastrointestinal System Test Questions
Question 1 of 5
An intubated patient is receiving continuous enteral feedings through a Salem sump tube at a rate of 60ml/hr. Gastric residuals have been 30-40ml when monitored Q4H. You check the gastric residual and aspirate 220ml. What is your first response to this finding?
Correct Answer: B
Rationale: The correct response, B) Stop the feeding, and clamp the NG tube, is based on the principle of patient safety and preventing complications. Aspirating 220ml of gastric residual suggests poor gastric emptying and potential risk for aspiration, which can lead to respiratory compromise. By stopping the feeding and clamping the NG tube, you are preventing the patient from receiving more feedings that could potentially exacerbate the situation. Option A) Notify the doctor immediately is not the first response because immediate action is needed to address the risk of aspiration. Waiting for a physician's response could delay necessary interventions. Option C) Discard the 220ml, and clamp the NG tube is incorrect because discarding the aspirate without taking action to prevent further feeding could still lead to complications. Option D) Give a prescribed GI stimulant such as metoclopramide (Reglan) is not appropriate in this situation as the priority is to address the immediate risk of aspiration rather than promoting gastric motility. In an educational context, understanding the significance of gastric residuals in enteral feedings is crucial for nurses caring for patients with NG tubes. Prompt recognition of abnormal findings and appropriate actions can prevent serious complications and promote patient safety in medical-surgical settings.
Question 2 of 5
When planning care for a client with ulcerative colitis who is experiencing symptoms, which client care activities can the nurse appropriately delegate to a unlicensed assistant?
Correct Answer: B
Rationale: In the context of caring for a client with ulcerative colitis experiencing symptoms, the correct answer is B) Providing skin care following bowel movements. This task can be appropriately delegated to an unlicensed assistant as it involves maintaining the client's hygiene and preventing skin breakdown, which aligns with their scope of practice and does not require specialized nursing assessment or medical decision-making. Option A, assessing the client's bowel sounds, involves a higher level of assessment that requires nursing judgment and skill, so it should not be delegated to an unlicensed assistant. Option C, evaluating the client's response to antidiarrheal medications, involves monitoring for potential side effects and effectiveness of the medication, which requires nursing assessment and critical thinking. Option D, administration of pain medication every 4 hours, involves medication administration, which is a nursing responsibility due to the need for accurate dosage calculation, understanding of potential side effects, and monitoring the client's response. Educationally, understanding delegation in nursing is crucial for ensuring safe and effective patient care. Nurses must be able to differentiate tasks that can be delegated to unlicensed personnel from those that require nursing expertise to provide appropriate care and uphold patient safety. This rationale highlights the importance of delegation principles and the significance of knowing each team member's scope of practice to optimize patient outcomes.
Question 3 of 5
A client with ulcerative colitis has an order to begin salicylate medication to reduce inflammation. The nurse instructs the client to take the medication:
Correct Answer: C
Rationale: The correct answer is C: After meals. Salicylate medications for ulcerative colitis should be taken after meals to minimize gastrointestinal irritation and enhance absorption. Taking the medication on an empty stomach (Choice B) may increase the risk of gastrointestinal side effects. Taking it 30 minutes before meals (Choice A) may not provide enough protection for the stomach lining. Taking it on arising (Choice D) is not recommended as it may not coincide with the peak absorption times of the medication.
Question 4 of 5
During the assessment of a client's mouth, the nurse notes the absence of saliva. The client is also complaining of pain near the area of the ear. The client has been NPO for several days because of the insertion of an NG tube. Based on these findings, the nurse suspects that the client is developing which of the following mouth conditions?
Correct Answer: C
Rationale: The correct answer is C, Parotitis. Parotitis, inflammation of the parotid glands, can occur due to the absence of saliva and dehydration, often associated with being NPO and having an NG tube. Stomatitis (choice A) is inflammation of the oral mucosa, not specifically related to absent saliva. Oral candidiasis (choice B) is a fungal infection that can occur in the mouth, not directly related to the absence of saliva. Gingivitis (choice D) is inflammation of the gums and is not typically associated with the absence of saliva and dehydration.
Question 5 of 5
The nurse evaluates the client's stoma during the initial post-op period. Which of the following observations should be reported immediately to the physician?
Correct Answer: B
Rationale: A dark red to purple stoma may indicate compromised blood flow or ischemia, which requires immediate medical attention. This color change could be a sign of inadequate blood supply to the stoma tissue, leading to tissue damage or necrosis. Reporting this observation promptly is crucial to prevent further complications. Choices A, C, and D are not indicative of immediate medical concern. A slightly edematous stoma, oozing a small amount of blood, or not expelling stool may not be uncommon findings during the initial post-op period and can be managed without urgent intervention.