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. Gail is scheduled for a cholecystectomy. After completion of preoperative teaching, Gail states,”If I lie still and avoid turning after the operation, I’ll avoid pain. Do you think this is a good idea?” What is the best response?

Correct answer: A

Rationale: The best response to Gail is to inform her that she will need to turn from side to side every 2 hours to prevent complications.

3. Sharon has cirrhosis of the liver and develops ascites. What intervention is necessary to decrease the excessive accumulation of serous fluid in her peritoneal cavity?

Correct answer: A

Rationale: Restricting fluids is necessary to decrease the excessive accumulation of serous fluid in the peritoneal cavity for a patient with ascites due to cirrhosis.

4. Leigh Ann is receiving pancrelipase (Viokase) for chronic pancreatitis. Which observation best indicates the treatment is effective?

Correct answer: D

Rationale: The effectiveness of pancrelipase (Viokase) for chronic pancreatitis is best indicated by stools being less fatty and decreased in frequency.

5. A nurse is reviewing the results of serum laboratory studies drawn on a client who is suspected of having hepatitis. The nurse interprets that an elevation in which of the following studies is the most specific indicator of the disease?

Correct answer: C

Rationale: Laboratory indicators of hepatitis include elevated liver enzymes, serum bilirubin level, and erythrocyte sedimentation rate is nonspecific test that indicates the presence of inflammation somewhere in the body. Elevated blood urea nitrogen may indicate renal dysfunction. A hemoglobin level is unrelated to this diagnosis.

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