ATI RN
Gastrointestinal System Nursing Exam Questions Questions
Question 1 of 5
A nurse is caring for a client who has just returned from the operating room following the creation of a colostomy. The nurse is assessing the drainage in the pouch attached to the site where the colostomy was formed and notes serosanguineous drainage. Which nursing action is most appropriate based on this assessment?
Correct Answer: B
Rationale: The correct answer is B: Document the amount and characteristics of the drainage. This is appropriate as serosanguineous drainage is expected after colostomy creation. Documenting helps monitor for any changes and provides crucial information for the healthcare team. Choice A (Notify the physician) is not necessary at this point as serosanguineous drainage is normal postoperatively. Choice C (Apply ice to the stoma site) and Choice D (Apply pressure to the site) are both incorrect actions that are not indicated in this situation and could potentially harm the client.
Question 2 of 5
A client is admitted with a diagnosis of ulcerative colitis. Which of the following symptoms should the nurse expect the client to report when responding to questions about his bowel elimination pattern?
Correct Answer: B
Rationale: The correct answer is B: Bloody, diarrheal stools. In ulcerative colitis, inflammation of the colon leads to symptoms such as bloody diarrhea. This occurs due to ulceration and inflammation of the colon lining. The presence of blood in the stool is a hallmark symptom of ulcerative colitis. The other choices are incorrect because: A: Constipation is not typically associated with ulcerative colitis. It is more common in conditions like irritable bowel syndrome. C: Steatorrhea, which is fatty, greasy stools, is not a common symptom of ulcerative colitis. D: Alternating periods of constipation and diarrhea are more indicative of conditions like irritable bowel syndrome or functional gastrointestinal disorders, not specifically ulcerative colitis.
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: The correct answer is A: Irrigating the nasogastric tube. After a Billroth II procedure, the client's stomach has been partially removed, making them prone to dumping syndrome. Irrigating the nasogastric tube can disrupt the natural digestive process and may exacerbate dumping syndrome. Instead, the focus should be on promoting slow, gradual feeding to prevent complications. Summary: B: Coughing and deep breathing exercises - Important for preventing respiratory complications postoperatively. C: Leg exercises - Essential for preventing blood clots and promoting circulation. D: Early ambulation - Encourages mobility and prevents complications such as pneumonia and blood clots.
Question 4 of 5
The nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client to:
Correct Answer: D
Rationale: The correct answer is D: drink liquids only between meals. This is because restricting fluids during meals can worsen dumping syndrome by rapidly emptying the stomach contents into the intestines, causing symptoms like cramping and diarrhea. By advising the client to drink liquids only between meals, it allows for better digestion and absorption of nutrients, reducing the risk of dumping syndrome. Choice A is incorrect because restricting fluid intake can lead to dehydration and other complications. Choice B is incorrect as drinking liquids with meals can exacerbate dumping syndrome symptoms. Choice C is incorrect as not drinking liquids before meals may not effectively manage dumping syndrome and can lead to dehydration.
Question 5 of 5
The nurse is irrigating a client's colostomy when she complains of abdominal cramping after receiving about 100 mL of the irrigating solution. What should the nurse's first response be in this situation?
Correct Answer: A
Rationale: The correct response is A: Stop the flow of solution temporarily. This is the appropriate action to take first in this situation to prevent further complications. By stopping the flow of the solution, the nurse can assess the client's condition and determine the cause of the abdominal cramping. Repositioning the client (B) or massaging the abdomen (D) may exacerbate the cramping if there is an underlying issue. Removing the irrigation tube (C) without proper assessment could lead to complications. It is essential to prioritize the client's safety and well-being by halting the irrigation process to address any immediate concerns.