a nurse is caring for a client who has just returned from the operating room following the creation of a colostomy the nurse is assessing the drainage
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Nursing Elites

ATI RN

Gastrointestinal System Nursing Exam Questions

1. A nurse is caring for a client who has just returned from the operating room following the creation of a colostomy. The nurse is assessing the drainage in the pouch attached to the site where the colostomy was formed and notes serosanguineous drainage. Which nursing action is most appropriate based on this assessment?

Correct answer: B

Rationale: During the first 24 to 72 hours following surgery, mucus and serosanguineous drainage are expected from the stoma. Documenting the amount and characteristics of the drainage is appropriate. The nurse does not need to notify the physician because this is an expected finding. Applying ice or pressure to the site is not necessary.

2. A nurse is inserting a nasogastric tube in an adult client. During the procedure, the client begins to cough and has difficulty breathing. Which of the following is the most appropriate nursing action?

Correct answer: B

Rationale: During the insertion of a nasogastric tube, if the client experiences difficulty breathing or any respiratory distress, withdraw the tube slightly, stop the tube advancement, and wait until the distress subsides. Options 1 and 4 are unnecessary. Quickly inserting the tube is not an appropriate action because, in this situation, it may be likely that the tube has entered the bronchus.

3. Before bowel surgery, Lee is to administer enemas until clear. During administration, he complains of intestinal cramps. What do you do next?

Correct answer: B

Rationale: If a patient complains of intestinal cramps during an enema, lowering the height of the enema container can help reduce discomfort.

4. Before administering an intermittent tube feeding through a nasogastric tube, the nurse assesses for gastric residual. The nurse understands that this procedure is important to

Correct answer: D

Rationale: Evaluating the absorption of the last feeding is important because administration of a tube feeding to a full stomach could result in overdistention, thus predisposing the client to regurgitation and possible aspiration.

5. Eleanor, a 62 y.o. woman with diverticulosis is your patient. Which interventions would you expect to include in her care?

Correct answer: C

Rationale: Care for a patient with diverticulosis includes a high-fiber diet and administration of psyllium.

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