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. If a gastric acid perforates, which of the following actions should not be included in the immediate management of the client?

Correct answer: B

Rationale: Antacid administration should not be included in the immediate management of a gastric perforation.

3. Develop a teaching care plan for Angie who is about to undergo a liver biopsy. Which of the following points do you include?

Correct answer: B

Rationale: Instruct the patient to lie on their right side after the biopsy to apply pressure and prevent bleeding.

4. Of the following signs and symptoms of bowel obstruction, which is related primarily to small bowel obstruction rather than large bowel obstruction?

Correct answer: A

Rationale: Profuse vomiting is the classic sign of small bowel obstruction and rarely occurs with large bowel obstruction. Abdominal discomfort and distention are present in both small and large bowel obstructions, but distention is more common in large bowel obstruction. High-pitched bowel sounds indicate hyperperistalsis, which occurs early in obstruction.

5. Which goal of the client’s care should take priority during the first days of hospitalization for an exacerbation of ulcerative colitis?

Correct answer: B

Rationale: Managing diarrhea should take priority during the first days of hospitalization for an exacerbation of ulcerative colitis.

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