the nurse is caring for a client on the first postoperative day following a surgical repair of an abdominal aortic aneurysm which nursing diagnosis is
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Nursing Elites

ATI RN

Gastrointestinal System Nursing Exam Questions

1. The nurse is caring for a client on the first postoperative day following a surgical repair of an abdominal aortic aneurysm. Which nursing diagnosis is the most important for this client?

Correct answer: C

Rationale: Peripheral tissue perfusion is a major concern in the postoperative period following an abdominal aneurysm repair. Peripheral pulses should be checked frequently during the first 24 hours. A weak or absent pulse may be a sign of embolization or graft closure, especially if accompanied by a pale, cold, mottled extremity; the nurse should immediately report this to the surgeon. Risk for infection, deficient knowledge, and activity intolerance are all important nursing diagnoses in the postoperative period, but peripheral tissue perfusion is the most immediate concern.

2. Which of the following measures should the nurse focus on for the client with esophageal varices?

Correct answer: A

Rationale: The primary focus for a client with esophageal varices is recognizing hemorrhage because these varices can rupture and cause significant bleeding.

3. Which area of the alimentary canal is the most common location for Crohn’s disease?

Correct answer: D

Rationale: The terminal ileum is the most common location for Crohn's disease.

4. The nurse is doing pre-op teaching with the client who is about to undergo creation of a Kock pouch. The nurse interprets that the client has the best understanding of the nature of the surgery if the client makes which of the following statements?

Correct answer: A

Rationale: A Kock pouch is a type of continent ileostomy that requires catheterization to empty the internal reservoir. Understanding the need for regular catheterization indicates the client comprehends the procedure.

5. When planning care for a client with ulcerative colitis who is experiencing symptoms, which client care activities can the nurse appropriately delegate to a unlicensed assistant?

Correct answer: D

Rationale: Delegating tasks such as providing skin care, maintaining intake and output records, and obtaining the client's weight are within the scope of practice for an unlicensed assistant. Assessing bowel sounds and evaluating the response to medications require nursing judgment and should not be delegated.

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