the nurse evaluates the clients stoma during the initial post op period which of the following observations should be reported immediately to the phys
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Nursing Elites

ATI RN

ATI Gastrointestinal System Test

1. The nurse evaluates the client’s stoma during the initial post-op period. Which of the following observations should be reported immediately to the physician?

Correct answer: B

Rationale: A dark red to purple stoma may indicate compromised blood flow or ischemia, which requires immediate medical attention. This color change could be a sign of inadequate blood supply to the stoma tissue, leading to tissue damage or necrosis. Reporting this observation promptly is crucial to prevent further complications. Choices A, C, and D are not indicative of immediate medical concern. A slightly edematous stoma, oozing a small amount of blood, or not expelling stool may not be uncommon findings during the initial post-op period and can be managed without urgent intervention.

2. Lactulose (Chronulac) is prescribed for a client with a diagnosis of hepatic encephalopathy. The nurse would determine that this medication has had a therapeutic effect if which of the following is noted?

Correct answer: B

Rationale: Lactulose is prescribed for the client with hepatic encephalopathy to reduce bacterial breakdown of protein in the bowel. The medication creates an acidic environment in the bowel and causes the ammonia to leave the bloodstream and enter the colon. Ammonia then becomes trapped in the bowel. Lactulose also has a laxative effect that allows for the elimination of the ammonia.

3. Annebell is being discharged with a colostomy, and you’re teaching her about colostomy care. Which statement correctly describes a healthy stoma?

Correct answer: A

Rationale: A healthy stoma may bleed slightly when touched initially, which is normal.

4. When a client has peptic ulcer disease, the nurse would expect a priority intervention to be:

Correct answer: C

Rationale: Inserting a nasogastric tube is a priority intervention for a client with peptic ulcer disease to decompress the stomach.

5. A client is scheduled for oral cholecystography. Which one of the following actions would the nurse plan to implement before the test?

Correct answer: B

Rationale: Iodine compounds used as radiographic contrast agents, such as iopanoic acid (Telepaque), should not be administered to the client with iodine and seafood allergies because anaphylaxis may occur.

Similar Questions

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Which of the following symptoms best describes Murphy’s sign?
The client has orders for a nasogastric (NG) tube insertion. During the procedure, instructions that will assist in the insertion would be:
Which of the following techniques would the nurse use first to determine if a nasogastric tube is positioned in the stomach?
The client with a duodenal ulcer may exhibit which of the following findings on assessment?

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