ATI RN
ATI Gastrointestinal System Quizlet Questions
Question 1 of 5
The client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate post-op period for which of the following most frequent complications of this type of surgery?
Correct Answer: B
Rationale: In the immediate post-op period following ileostomy surgery, the nurse must prioritize assessment for fluid and electrolyte imbalance as the most frequent complication. This is because an ileostomy bypasses a significant portion of the small intestine where most fluid and electrolyte absorption occurs. As a result, there is a risk of dehydration, electrolyte imbalances (such as sodium and potassium), and acid-base disturbances. These complications can lead to serious consequences like cardiac arrhythmias, muscle weakness, and neurological issues. Option A, intestinal obstruction, is less likely in the immediate post-op period as the stoma is newly created. Malabsorption of fat (Option C) and folate deficiency (Option D) are long-term complications that may occur with an ileostomy but are not immediate concerns post-surgery. Educationally, understanding the priority of assessing for fluid and electrolyte imbalance post-ileostomy surgery is crucial for nursing students to provide safe and effective care to patients undergoing gastrointestinal surgeries. Emphasizing this knowledge helps students develop critical thinking skills in prioritizing assessments and interventions based on the patient's condition.
Question 2 of 5
The client with a colostomy has an order for irrigation of the colostomy. The nurse used which solution for irrigation?
Correct Answer: B
Rationale: In the context of medical surgical nursing, understanding the rationale behind colostomy care, specifically irrigation solutions, is crucial for providing safe and effective patient care. In this scenario, the correct answer is option B: Tap water. Rationale for the correct answer: Tap water is the appropriate solution for colostomy irrigation because it is isotonic and poses a lower risk of electrolyte imbalances compared to other solutions. Tap water is readily available, cost-effective, and generally well-tolerated by the body, making it a suitable choice for irrigation procedures. Rationale for why others are wrong: A) Distilled water is hypotonic and can lead to electrolyte imbalances if absorbed systemically. C) Sterile water, while free of microorganisms, lacks essential electrolytes present in tap water. D) Lactated Ringer's is a balanced electrolyte solution typically used for intravenous administration, not for colostomy irrigation. Educational context: Understanding the rationale behind selecting the appropriate irrigation solution for a colostomy is essential for nurses caring for patients with ostomies. By choosing tap water, nurses can help maintain electrolyte balance and prevent complications associated with using solutions that may disrupt the body's homeostasis. This knowledge enhances nursing practice and ensures the safety and well-being of patients with colostomies.
Question 3 of 5
A nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis. The client is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment the nurse notes that the abdomen is distended and the bowel sounds are diminished. Which of the following is the most appropriate nursing intervention?
Correct Answer: B
Rationale: In this scenario, the most appropriate nursing intervention is to select option B, which is to notify the physician. This is the correct choice because the client is exhibiting signs of a potential complication related to appendicitis, such as increased abdominal pain, vomiting, distended abdomen, and diminished bowel sounds. These symptoms could indicate a worsening condition, such as appendiceal perforation or peritonitis, which require immediate medical attention and possibly a change in the surgical plan. Option A, administering dilaudid, is not the correct choice in this situation because managing pain should not be the priority when the client is showing signs of a potential surgical emergency. Delaying necessary medical intervention by trying to manage pain pharmacologically can lead to serious complications. Option C, calling the operating room team to perform the surgery as soon as possible, is not the most appropriate action because the client's current condition needs to be assessed by the physician before proceeding with surgery. Rushing into surgery without a proper evaluation could be dangerous and lead to unnecessary risks. Option D, repositioning the client and applying a heating pad, is also not the best choice as heat application can potentially worsen the condition if there is an underlying surgical emergency. It is crucial to prioritize medical assessment and intervention over comfort measures in this situation. Educationally, this scenario highlights the importance of recognizing early signs of complications in patients with appendicitis and the significance of prompt communication with the healthcare team. It emphasizes the critical role of nursing assessment in identifying changes in a patient's condition and advocating for appropriate medical intervention to ensure patient safety and optimal outcomes.
Question 4 of 5
The client has been admitted with a diagnosis of acute pancreatitis. The nurse would assess this client for pain that is:
Correct Answer: A
Rationale: In the context of acute pancreatitis, the correct answer is option A) Severe and unrelenting, located in the epigastric area and radiating to the back. This type of pain presentation is characteristic of pancreatitis due to the inflammation and distention of the pancreas, which can cause severe, constant pain that typically starts in the epigastric region and may radiate to the back. Option B) Severe and unrelenting, located in the left lower quadrant and radiating to the groin is incorrect because this type of pain pattern is more indicative of conditions like diverticulitis or appendicitis, not pancreatitis. Option C) Burning and aching, located in the epigastric area and radiating to the umbilicus does not match the typical pain pattern seen in acute pancreatitis. The pain in pancreatitis is usually described as severe and can be dull or piercing rather than burning or aching. Option D) Burning and aching, located in the left lower quadrant and radiating to the hip is not characteristic of pancreatitis. Pain in the left lower quadrant radiating to the hip is more commonly associated with conditions like ovarian cysts or kidney stones. Educationally, understanding the specific pain patterns associated with different conditions is crucial for nurses to accurately assess and provide appropriate care for patients with gastrointestinal issues like acute pancreatitis. Recognizing these nuances can aid in timely diagnosis and intervention, improving patient outcomes.
Question 5 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 this scenario, the correct answer is option A) Lying supine with the legs straight. The rationale behind this is that maintaining a supine position with the legs straight can exacerbate abdominal pain in clients with Crohn's disease due to increased intra-abdominal pressure and potential strain on the abdomen. Option B) Massaging the abdomen can actually help alleviate some abdominal discomfort by promoting relaxation and aiding in easing muscle tension. Option C) Using antispasmodic medication may be appropriate for managing abdominal pain in Crohn's disease by reducing spasms in the intestines. Option D) Using relaxation techniques such as deep breathing or guided imagery can be beneficial in managing pain and stress associated with Crohn's disease. In an educational context, it is crucial for nursing students to understand the specific needs of clients with Crohn's disease and how certain interventions can either alleviate or worsen their symptoms. Teaching clients to avoid positions or activities that can exacerbate their pain is essential in their overall management and quality of life.