ATI RN
ATI Gastrointestinal System Questions
Question 1 of 5
The nurse is caring for a client with a diagnosis of cirrhosis and is monitoring the client for signs of portal hypertension. Which initial sign, if noted in the client, indicates the presence of portal hypertension?
Correct Answer: D
Rationale: Rationale: 1. The correct answer is D) Crackles on auscultation of the lungs. Portal hypertension is a complication of cirrhosis where increased pressure in the portal vein system leads to various manifestations. Crackles on lung auscultation indicate hepatic hydrothorax, a common consequence of portal hypertension where ascites fluid enters the pleural space, causing crackling sounds upon breathing. 2. A) Flat neck veins are not indicative of portal hypertension. In fact, in portal hypertension, engorged neck veins (jugular venous distension) are commonly seen due to increased venous pressure. B) Hypotension is not a typical sign of portal hypertension. Instead, hypertension or normal blood pressure is more common in these cases. C) Weak pulse is not a direct sign of portal hypertension. Peripheral pulses may actually be bounding due to the hyperdynamic circulation seen in conditions like cirrhosis. 3. Understanding the signs of portal hypertension is crucial in caring for patients with liver disease. Monitoring for crackles on lung auscultation can help in early detection of complications like hepatic hydrothorax, prompting timely interventions. It is essential for nurses to be vigilant in assessing these patients for subtle changes that could indicate worsening liver function and portal hypertension.
Question 2 of 5
The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis. The client is scheduled for surgery for 2 hours. The client begins to complain of increases abdominal pain and begins to vomit. On assessment the nurse notes that the abdomen distended and bowel sounds are diminished. Which of the following is the most appropriate nursing intervention?
Correct Answer: B
Rationale: Based on the signs and symptoms presented in the question, the nurse should suspect peritonitis and should notify the physician. Administering pain medication is not an appropriate intervention. Heat should never be applied to the abdomen of a client with suspected appendicitis. Scheduling surgical time is not within the scope of nursing practice, although the physician probably would perform the surgery earlier than the prescheduled time.
Question 3 of 5
A nurse is caring for a client diagnose with pancreatitis. The nurse anticipates that the client would not experience an elevation of which of the following enzymes?
Correct Answer: B
Rationale: Rationale: 1. The correct answer is B) Lactase. Lactase is an enzyme responsible for breaking down lactose (milk sugar). Pancreatitis primarily affects enzymes produced by the pancreas, such as lipase, amylase, and trypsin. Lactase is produced by the small intestine, not the pancreas. Therefore, in pancreatitis, lactase levels would not be directly affected. 2. A) Lipase is an enzyme produced by the pancreas that helps digest fats. In pancreatitis, lipase levels are typically elevated due to pancreatic inflammation and damage. 3. C) Amylase is another enzyme produced by the pancreas that aids in digesting carbohydrates. In pancreatitis, amylase levels are often elevated, as the inflamed pancreas leaks this enzyme into the bloodstream. 4. D) Trypsin is an enzyme produced by the pancreas to digest proteins. In pancreatitis, trypsin levels can be elevated due to the release of digestive enzymes into the pancreas itself, leading to auto-digestion and further damage. Key Learning Points: - Pancreatitis is an inflammatory condition affecting the pancreas. - Elevated levels of lipase and amylase are common markers of pancreatitis. - Lactase is not produced by the pancreas but by the small intestine. - Understanding enzyme functions and origins helps in diagnosing and managing pancreatic disorders. In conclusion, recognizing the specific enzymes affected in pancreatitis is crucial for accurate assessment and treatment. Lactase remains unaffected in pancreatitis, distinguishing it from the other enzymes typically elevated in this condition.
Question 4 of 5
The client is admitted to the hospital for treatment of acute hepatitis B. Which activity order would the nurse expect to be prescribed?
Correct Answer: A
Rationale: Rationale: 1. The correct answer is A) Bedrest. Acute hepatitis B is a viral infection that affects the liver, causing inflammation and damage. Bedrest is essential in the treatment of acute hepatitis B to reduce metabolic demands on the liver, promote healing, and prevent complications. Rest helps to conserve energy, reduce liver workload, and facilitate the body's immune response to fight the infection. 2. Option B) Encourage ambulation is incorrect because excessive physical activity can increase the metabolic demands on the liver, leading to further stress and potential complications. Rest is crucial for the liver to recover and regenerate. 3. Option C) Out of bed in a chair is also incorrect as it involves more physical activity than bedrest and may not provide the necessary rest for the liver to heal efficiently. Prolonged sitting may also increase the risk of complications like deep vein thrombosis. 4. Option D) No activity restrictions is incorrect because patients with acute hepatitis B require activity restrictions, especially during the acute phase of the illness. Engaging in strenuous activities can exacerbate liver inflammation and delay recovery. Educating patients on the importance of rest is vital in managing acute hepatitis B effectively.
Question 5 of 5
The physician orders a Salem sump tube for gastrointestinal intubation. The nurse prepares for the insertion and obtains which of the following items from the supply room?
Correct Answer: B
Rationale: Rationale: 1. The correct answer is B) A tube with a large lumen and an air vent. A Salem sump tube is a type of nasogastric tube designed for gastrointestinal intubation. It has two lumens - one for suctioning gastric contents and the other, the air vent, to prevent the tube from adhering to the gastric mucosa and causing injury during suctioning. 2. Option A) A tube with a single lumen that connects to suction is incorrect because a Salem sump tube requires two lumens for its specific functions - one for suction and the other for the air vent. 3. Option C) A Sengstaken-Blakemore tube is used for controlling esophageal or gastric variceal bleeding, not for routine gastrointestinal intubation. 4. Option D) A Dobbhoff weighted tube is a type of feeding tube used for enteral feeding, not for gastrointestinal intubation like the Salem sump tube. Educational context: Understanding the specific characteristics and purposes of different types of tubes used in gastrointestinal interventions is crucial for nurses in providing safe and effective patient care. Knowing the features of each tube helps in selecting the appropriate device for the prescribed procedure, ensuring patient comfort and safety during tube insertion and maintenance.