ATI RN
Gastrointestinal System Nursing Exam Questions Questions
Question 1 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 2 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.
Question 3 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: The correct answer is C. The rationale is as follows: The return of bowel function, evidenced by passing gas, is an important indicator of gastrointestinal motility and recovery postoperatively. It indicates that the gastrointestinal system is beginning to function normally, which is a key factor in determining when the nasogastric tube can be safely removed. Choices A and B are too general and do not provide a specific physiological indicator for tube removal. Choice D defers the decision solely to the doctor without considering the client's physiological progress. Therefore, the most appropriate and accurate indicator for tube removal is the return of bowel function and passage of gas, as stated in option C.
Question 4 of 5
A Penrose drain is in place on the first postoperative day following a cholecystectomy. Serosanguineous drainage is noted on the dressing covering the drain. Which nursing intervention is most appropriate?
Correct Answer: B
Rationale: The correct answer is B: Change the dressing. This is the most appropriate intervention because serosanguineous drainage can indicate the need for a dressing change to prevent infection and ensure proper wound healing. Changing the dressing will also allow for better assessment of the drainage and the incision site. A: Notifying the physician may not be necessary at this stage since serosanguineous drainage is expected in the early postoperative period. C: Circling the amount on the dressing with a pen does not address the need for a dressing change or further assessment of the drainage. D: Continuing to monitor the drainage is important, but changing the dressing is the immediate action needed to ensure proper wound care.
Question 5 of 5
The nurse is monitoring a client for the early signs and symptoms for dumping syndrome. Which symptom indicates this occurrence?
Correct Answer: C
Rationale: The correct answer is C, sweating and pallor, for early signs of dumping syndrome. Dumping syndrome is characterized by rapid emptying of the stomach contents into the small intestine, leading to symptoms like diaphoresis (sweating) and pallor due to vasomotor instability. Abdominal cramping and pain (A) are more commonly associated with gastrointestinal issues, not specific to dumping syndrome. Bradycardia and indigestion (B) are not typical symptoms of dumping syndrome, as it usually presents with tachycardia due to fluid shifts. Double vision and chest pain (D) are not commonly associated with dumping syndrome.