ATI RN
ATI Gastrointestinal System Quizlet Questions
Question 1 of 5
The nurse is assessing for stoma prolapse in a client with a colostomy. The nurse would observe which of the following if stoma prolapse occurred?
Correct Answer: D
Rationale: In this scenario, the correct answer is D) Protruding stoma. When a stoma prolapse occurs in a client with a colostomy, the stoma will protrude further out from the abdominal wall than usual. This happens due to the weakening of the surrounding muscles and support structures, causing the stoma to extend beyond its normal position. Option A) Sunken and hidden stoma is incorrect because a sunken stoma would signify a retracted or inwardly positioned stoma, which is not indicative of prolapse. Option B) Dark- and bluish-colored stoma is incorrect as discoloration would suggest ischemia or inadequate blood supply to the stoma, not prolapse. Option C) Narrowed and flattened stoma is incorrect as these characteristics do not align with the physical presentation of a prolapsed stoma. Educationally, understanding the signs and symptoms of stoma complications like prolapse is crucial for nurses caring for patients with ostomies. Recognizing these changes early can help prevent further complications and promote timely intervention and management. Nurses should also educate patients on stoma care, signs of complications, and when to seek medical assistance to promote optimal outcomes and quality of life for individuals with ostomies.
Question 2 of 5
The nurse has given instructions to the client with an ileostomy about foods to eat to thicken the stool. The nurse determines that the client needs further instructions if the client stated to eat which of the following foods to make the stools less watery?
Correct Answer: C
Rationale: In the context of a client with an ileostomy, it is essential to provide education on dietary choices that can help regulate stool consistency. The correct answer, option C (Bran), is incorrect because bran is a high-fiber food that can actually exacerbate diarrhea and lead to watery stools in individuals with an ileostomy. Option A (Pasta) and option B (Boiled rice) are both low-fiber foods that can help thicken stool and reduce water content, making them appropriate choices for individuals with an ileostomy. These foods are less likely to contribute to diarrhea or increased stool output. Option D (Low-fat cheese) does not have a significant impact on stool consistency and is not specifically known to thicken or make stool less watery. Educationally, it is important for nurses to understand the rationale behind dietary recommendations for clients with an ileostomy to ensure optimal patient outcomes. Providing accurate information on appropriate food choices can help prevent complications such as diarrhea or dehydration in this population.
Question 3 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 4 of 5
The nurse is doing pre-op teaching with the client who is about to undergo creation of a Kock pouch. The nurse interprets that the client has the best understanding of the nature of the surgery if the client makes which of the following statements?
Correct Answer: A
Rationale: In this scenario, option A is the correct response. The statement "I will need to drain the pouch regularly with a catheter" demonstrates a clear understanding of the Kock pouch procedure. In a Kock pouch surgery, a continent ileostomy is created, and the client needs to self-catheterize to empty the pouch regularly. This statement shows the client understands the need for ongoing care and maintenance of the pouch. Option B is incorrect because wearing a drainage bag for life is not characteristic of a Kock pouch. Option C is incorrect because a Kock pouch is continent and does not continuously drain; the drainage is periodic via catheterization. Option D is incorrect because a Kock pouch diverts the stool away from the rectum, so the client will not pass stool through the rectum post-surgery. Educationally, this question emphasizes the importance of pre-operative teaching in ensuring patient understanding and cooperation. Nurses play a crucial role in preparing patients for surgery by providing accurate information and addressing any concerns or misconceptions. Understanding the specifics of different ostomy procedures is essential for both nurses and patients to ensure successful post-operative outcomes.
Question 5 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.