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. The student nurse is participating in colorectal cancer-screening program. Which patient has the fewest risk factors for colon cancer?

Correct answer: C

Rationale: Herman, a 60 y.o. who follows a low-fat, high-fiber diet, has the fewest risk factors for colon cancer.

3. Brenda, a 36 y.o. patient is on your floor with acute pancreatitis. Treatment for her includes:

Correct answer: C

Rationale: Treatment for acute pancreatitis includes nutritional support with TPN.

4. Fistulas are most common with which of the following bowel disorders?

Correct answer: A

Rationale: Fistulas are most common in Crohn's disease due to the transmural inflammation that characterizes this condition.

5. The nurse assesses the client's understanding of the relationship between body position and gastroesophageal reflux. Which response would indicate that the client understands measures to avoid problems with reflux while sleeping?

Correct answer: D

Rationale: Sleeping with the head of the bed elevated encourages movement of food through the esophagus by gravity. By fostering esophageal acid clearance, gravity helps keep the acidic pepsin and alkaline biliary secretions from contacting the esophagus. Elevating the foot of the bed does not affect clearance of esophageal acid. Sleeping on the stomach with the head turned to the left will not decrease reflux incidence. Sleeping flat without a pillow under the head does not enhance clearance.

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