ATI RN
Gastrointestinal System Nursing Exam Questions Questions
Question 1 of 5
A client returns from surgery with a sigmoid colostomy. An ostomy appliance is attached. The priority nursing diagnosis for daily observation and care is:
Correct Answer: B
Rationale: The correct answer is B: Impaired skin integrity related to seepage. This is the priority nursing diagnosis because a colostomy appliance can lead to skin breakdown due to seepage of stool, which can cause irritation and skin breakdown. Maintaining skin integrity is crucial to prevent infection and promote healing. A: Diarrhea is not the priority as it is a common issue after colostomy surgery but can be managed with appropriate interventions. C: Impaired nutrition is not the priority as it is not specifically related to the immediate care of the colostomy appliance. D: Impaired physical mobility is not the priority as it is not directly related to the immediate care of the colostomy appliance. In summary, choice B is the correct answer because maintaining skin integrity is essential for the client's well-being and to prevent complications associated with a colostomy appliance.
Question 2 of 5
A nurse is developing a plan of care for a client who will be returning to a nursing unit following a percutaneous transhephatic cholangiogram. The nurse includes which intervention in the postprocedure plan of care?
Correct Answer: A
Rationale: The correct answer is A: Place a sandbag over the insertion site. This intervention helps maintain pressure on the puncture site, reducing the risk of bleeding or hematoma formation post-procedure. Placing a sandbag over the insertion site is a standard practice to ensure hemostasis and prevent complications. Explanation for incorrect choices: B: Allowing bathroom privileges only is unrelated to the specific care needs following a percutaneous transhepatic cholangiogram. C: Encouraging fluid intake is a general nursing intervention and does not directly address the postprocedure care requirements for this specific procedure. D: Allowing the client to sit in a chair for meals is not a priority post-procedure and does not address the potential complications associated with the puncture site.
Question 3 of 5
The client with a new colostomy is concerned about the odor from stool from the ostomy drainage bag. The nurse teaches the client to include which of the following foods in the diet to reduce odor?
Correct Answer: A
Rationale: The correct answer is A: Yogurt. Yogurt contains probiotics that help maintain a healthy balance of gut bacteria, which can reduce the odor of stool in the ostomy drainage bag. Probiotics can also improve digestion and overall gut health. Broccoli (B) and eggs (D) can actually contribute to stronger odors due to their sulfur content. Cucumbers (C) are low in fiber and may not have a significant impact on stool odor.
Question 4 of 5
The nurse has inserted a nasogastric tube to the level of the oropharynx and has repositioned the client's head in a flexed-forward position. The client has been asked to begin swallowing. The nurse starts slowly to advance the nasogastric tube with each swallow. The client begins to cough, gag, and choke. Which nursing action would least likely result in proper tube insertion and promote client relaxation?
Correct Answer: A
Rationale: Correct Answer: A Rationale: 1. The client is experiencing coughing, gagging, and choking, indicating improper tube insertion. 2. Continuing to advance the tube can lead to further discomfort and potential complications. 3. Pulling the tube back slightly allows for reevaluation of placement and prevents further irritation. 4. Checking the back of the pharynx can identify any obstruction or incorrect placement. 5. Instructing the client to breathe slowly and take sips of water can help relax the client and facilitate proper insertion.
Question 5 of 5
A nurse is giving dietary instructions to a client who has a new colostomy. The nurse encourages the client to eat foods representing which of the following diets for the first 4 to 6 weeks postoperatively?
Correct Answer: D
Rationale: The correct answer is D: Low-residue. After colostomy surgery, the bowel needs time to heal. A low-residue diet helps reduce the amount of undigested food passing through the colon, easing digestion and minimizing strain on the stoma. This diet typically includes easily digestible foods like white bread, rice, pasta, and well-cooked vegetables. High-protein (choice A) and high-carbohydrate (choice B) diets can be harder to digest and may cause discomfort. A low-calorie diet (choice C) is not necessary during the initial postoperative period when the focus should be on promoting healing and comfort.