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 nurse is caring for a client admitted to the hospital with a suspected diagnosis of acute appendicitis. Which of the following laboratory results would the nurse expect to note if the client indeed has appendicitis?

Correct answer: C

Rationale: Laboratory findings do not establish the diagnosis of appendicitis, but often moderate elevation of the white blood cell count (leukocytosis) to 10,000 to 18,000 cells/mm3 occurs with a “shift to the left” (an increased number of immature white blood cells.).

3. During the first few days of recovery from ostomy surgery for ulcerative colitis, which of the following aspects should be the first priority of client care?

Correct answer: D

Rationale: During the initial recovery period from ostomy surgery, skin care is the first priority to prevent irritation and infection around the stoma site.

4. The nurse provides medication instructions to a client with peptic ulcer disease. Which statement, if made by the client, indicates the best understanding of the medication therapy?

Correct answer: A

Rationale: Cimetidine (Tagamet) works by reducing stomach acid production, which helps to manage peptic ulcer disease.

5. What information is correct about stomach cancer?

Correct answer: A

Rationale: Stomach pain is often a late symptom of stomach cancer.

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