a client is scheduled for an abdominal perineal resection with permanent colostomy which of the following measures would most likely be included in th
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Nursing Elites

ATI RN

Gastrointestinal System Nursing Exam Questions

1. A client is scheduled for an abdominal perineal resection with permanent colostomy. Which of the following measures would most likely be included in the plan for the client's preoperative preparation?

Correct answer: B

Rationale: Antibiotics are administered preoperatively to reduce the bacterial count in the colon. The client will be placed on a low residue diet to help cleanse the bowel before surgery but typically is not placed on NPO status until 8 to 12 hours before surgery. Laxatives and enemas may also be administered. Chest tubes would not be expected postoperatively. There is no need to limit the client's activity before surgery.

2. A client with gastric cancer can expect to have surgery for resection. Which of the following should be the nursing management priority for the preoperative client with gastric cancer?

Correct answer: B

Rationale: The priority for preoperative management of a client with gastric cancer is the correction of nutritional deficits.

3. The client has orders for a nasogastric (NG) tube insertion. During the procedure, instructions that will assist in the insertion would be:

Correct answer: A

Rationale: Instructing the client to tilt his head back for insertion in the nostril, then flex his neck for the final insertion helps facilitate the NG tube insertion.

4. The nurse is caring for a client on the first postoperative day following a surgical repair of an abdominal aortic aneurysm. Which nursing diagnosis is the most important for this client?

Correct answer: C

Rationale: Peripheral tissue perfusion is a major concern in the postoperative period following an abdominal aneurysm repair. Peripheral pulses should be checked frequently during the first 24 hours. A weak or absent pulse may be a sign of embolization or graft closure, especially if accompanied by a pale, cold, mottled extremity; the nurse should immediately report this to the surgeon. Risk for infection, deficient knowledge, and activity intolerance are all important nursing diagnoses in the postoperative period, but peripheral tissue perfusion is the most immediate concern.

5. A nurse is providing instructions to a client who will collect a stool specimen for occult blood. The nurse instructs the client to avoid which of the following for 3 days before the collection of the stool specimen?

Correct answer: C

Rationale: The correct answer is C: Turnips. The nurse would instruct the client to avoid red meat, poultry, fish, turnips, horseradish, and foods such as fruits and vegetables for 3 days before and during testing. These products may alter test results. Choices A, B, and D are incorrect because they are not specifically mentioned as items to avoid before collecting a stool specimen for occult blood.

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