the nurse is assessing a 71 year old female client with ulcerative colitis which assessment finding related to the family will have the greatest impac
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Nursing Elites

ATI RN

Gastrointestinal System Nursing Exam Questions

1. The nurse is assessing a 71-year-old female client with ulcerative colitis. Which assessment finding related to the family will have the greatest impact on the client's rehabilitation after discharge?

Correct answer: C

Rationale: Emotional support from the family is the main need. A special diet doesn't focus on emotional needs. Role expectations don't address the main issue, but emotional support while the client is fulfilling these roles is important. The family's ability to understand the ups and downs of the illness will help them but not the client.

2. The physician orders a Salem sump tube for gastrointestinal intubation. The nurse prepares for the insertion and obtains which of the following items from the supply room?

Correct answer: B

Rationale: A tube with a large lumen and an air vent is a Salem sump tube. A tube with a single lumen is called a Levin’s tube. A Sengstaken-Blakemore tube is used to control bleeding in the esophagus. A Dobbhoff weighted tube is used for feedings.

3. A nurse is caring for a client who has just returned from the operating room following the creation of a colostomy. The nurse is assessing the drainage in the pouch attached to the site where the colostomy was formed and notes serosanguineous drainage. Which nursing action is most appropriate based on this assessment?

Correct answer: B

Rationale: During the first 24 to 72 hours following surgery, mucus and serosanguineous drainage are expected from the stoma. Documenting the amount and characteristics of the drainage is appropriate. The nurse does not need to notify the physician because this is an expected finding. Applying ice or pressure to the site is not necessary.

4. The nurse is performing a colostomy irrigation on a client. During the irrigation, a client begins to complain of abdominal cramps. Which of the following is the most appropriate nursing action?

Correct answer: C

Rationale: If a client experiences abdominal cramps during a colostomy irrigation, it is appropriate to stop the irrigation temporarily to allow the cramps to subside.

5. When obtaining a nursing history on a client with a suspected gastric ulcer, which signs and symptoms would the nurse expect to see? Select ONE that does not apply.

Correct answer: B

Rationale: Signs and symptoms of a gastric ulcer include epigastric pain at night, vomiting, and weight loss. Relief of epigastric pain after eating is not typically associated with gastric ulcers.

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