a client returns from surgery with a sigmoid colostomy an ostomy appliance is attached the priority nursing diagnosis for daily observation and care i
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Nursing Elites

ATI RN

Gastrointestinal System Nursing Exam Questions

1. A client returns from surgery with a sigmoid colostomy. An ostomy appliance is attached. The priority nursing diagnosis for daily observation and care is:

Correct answer: B

Rationale: Impaired skin integrity would be the priority nursing diagnosis for daily care of the colostomy because the effluent from the colostomy can be irritating to the skin. Diarrhea isn't a concern at this point. The client will be allowed nothing by mouth until peristalsis returns. The client should get out of bed on the first postoperative day, so mobility shouldn't be a problem.

2. The student nurse is teaching the family of a patient with liver failure. You instruct them to limit which foods in the patient’s diet?

Correct answer: A

Rationale: For a patient with liver failure, it is important to limit the intake of meats and beans to reduce the risk of hepatic encephalopathy.

3. 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.

4. Which of the following diets is most commonly associated with colon cancer?

Correct answer: A

Rationale: A low-fiber, high-fat diet is most commonly associated with an increased risk of colon cancer.

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: Serosanguineous drainage with a small amount of bile is expected from the Penrose drain for the first 24 hours. Drainage then decreases, and the drain is removed usually within 48 hours. The nurse does not need to notify the physician. A sterile dressing covers the site and should be changed to prevent infection and skin excoriation.

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