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. Your patient with peritonitis is NPO and complaining of thirst. What is your priority?

Correct answer: C

Rationale: Providing frequent mouth care is the priority for a patient with peritonitis who is NPO and complaining of thirst.

3. A client with ulcerative colitis is diagnosed with a mild case of the disease. The nurse doing dietary teaching gives the client examples of foods to eat that represent which of the following therapeutic diets?

Correct answer: C

Rationale: The client with a mild case of ulcerative colitis is often advised to follow a diet low in roughage and avoid milk. This dietary approach helps reduce the frequency of diarrhea in these clients. Therefore, the correct therapeutic diet for the client with ulcerative colitis in this scenario is a low-roughage diet without milk. Choices A, B, and D are incorrect because high-fat, high-protein, and low-roughage with milk diets are not typically recommended for clients with ulcerative colitis, especially those with mild cases.

4. The nurse is caring for a client with cirrhosis. Which manifestations indicate deficient vitamin K absorption caused by this liver disease?

Correct answer: C

Rationale: A liver disorder, such as cirrhosis, can disrupt the liver's normal use of vitamin K to produce prothrombin (a clotting factor). Because of this, the nurse should monitor the client for signs of bleeding, including purpura and petechiae. Dyspnea and fatigue suggest anemia. Ascites and orthopnea are unrelated to vitamin K absorption. Gynecomastia and testicular atrophy result from decreased estrogen metabolism by the diseased liver.

5. Hepatic encephalopathy develops when the blood level of which substance increases?

Correct answer: A

Rationale: Hepatic encephalopathy develops when the blood level of ammonia increases.

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