ATI RN
Gastrointestinal System Nursing Exam Questions Questions
Question 1 of 5
The client with Crohn's disease has a nursing diagnosis of Acute Pain. The nurse would teach the client to avoid which of the following in managing this problem?
Correct Answer: A
Rationale: In managing acute pain associated with Crohn's disease, the client should avoid lying supine with the legs straight. This position increases muscle tension in the abdomen, potentially aggravating inflamed intestinal tissues as the abdominal muscles are stretched. Massaging the abdomen, using antispasmodic medication, and employing relaxation techniques are beneficial in alleviating pain. Massaging can help relax abdominal muscles, antispasmodic medication can reduce spasms contributing to pain, and relaxation techniques aid in overall pain management. Therefore, choices B, C, and D are appropriate interventions for managing pain in clients with CroCrohn's disease.
Question 2 of 5
A nurse is developing a teaching plan for the client with viral hepatitis. The nurse plans to tell the client which of the following in the teaching session?
Correct Answer: A
Rationale: The client with viral hepatitis should limit activity to avoid fatigue during the recuperation period. The diet should be optimal in calories, proteins, and carbohydrates. The client should take in several small meals per day. Alcohol is strictly forbidden.
Question 3 of 5
The nurse is caring for a client following a Billroth II procedure. On review of the postoperative orders, which of the following if prescribed, should the nurse question and verify?
Correct Answer: A
Rationale: In a Billroth II procedure the proximal remnant of the stomach is anastomosed to the proximal jejunum. Patency of the nasogastric tube is critical for preventing the retention of gastric secretions. The nurse should never irrigate or reposition the gastric tube after gastric surgery, unless specifically ordered by the physician. In this situation the nurse should clarify the order. Coughing and deep breathing exercises, leg exercises, and early ambulation are appropriate postoperative interventions.
Question 4 of 5
A nurse teaches a preoperative client about the nasogastric tube that will be inserted in preparation for surgery. The nurse determines that the client understands when the tube will be removed in the postoperative period when the client states
Correct Answer: C
Rationale: Nasogastric tubes are discontinued when normal function returns to the gastrointestinal tract. The tube will be removed before gastrointestinal healing. Food would not be administered unless bowel function returns. Although the physician determines when the nasogastric tube will be removed, option 4 does not determine effectiveness of teaching.
Question 5 of 5
The nurse is caring for a client on the first postoperative day following a surgical repair of an abdominal aortic aneurysm. Which nursing diagnosis is the most important for this client?
Correct Answer: C
Rationale: Peripheral tissue perfusion is a major concern in the postoperative period following an abdominal aneurysm repair. Peripheral pulses should be checked frequently during the first 24 hours. A weak or absent pulse may be a sign of embolization or graft closure, especially if accompanied by a pale, cold, mottled extremity; the nurse should immediately report this to the surgeon. Risk for infection, deficient knowledge, and activity intolerance are all important nursing diagnoses in the postoperative period, but peripheral tissue perfusion is the most immediate concern.
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