the nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis the client is scheduled for surgery for 2 hours the client
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Nursing Elites

ATI RN

ATI Gastrointestinal System

1. The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis. The client is scheduled for surgery for 2 hours. The client begins to complain of increases abdominal pain and begins to vomit. On assessment the nurse notes that the abdomen distended and bowel sounds are diminished. Which of the following is the most appropriate nursing intervention?

Correct answer: B

Rationale: Based on the signs and symptoms presented in the question, the nurse should suspect peritonitis and should notify the physician. Administering pain medication is not an appropriate intervention. Heat should never be applied to the abdomen of a client with suspected appendicitis. Scheduling surgical time is not within the scope of nursing practice, although the physician probably would perform the surgery earlier than the prescheduled time.

2. A client is admitted with a diagnosis of ulcerative colitis. Which of the following symptoms should the nurse expect the client to report when responding to questions about his bowel elimination pattern?

Correct answer: B

Rationale: Diarrhea is the primary symptom of ulcerative colitis. It is profuse and severe; the client may pass as many as 15 to 20 watery stools per day. Stools may contain blood, mucus, and pus. The frequent diarrhea is often accompanied by anorexia and nausea. Constipation is not a sign or symptom of ulcerative colitis. Steatorrhea (fatty stools) is more typical of pancreatitis and cholecystitis. Alternating diarrhea and constipation is associated with irritable bowel syndrome.

3. Which of the following diagnostic tests should be performed annually over age 50 to screen for colon cancer?

Correct answer: D

Rationale: A fecal occult blood test should be performed annually for individuals over age 50 to screen for colon cancer.

4. Which of the following expected outcomes would be appropriate for the client who has ulcerative colitis?

Correct answer: B

Rationale: Small, frequent feedings are better tolerated by clients with ulcerative colitis as they lessen the amount of fecal material present in the gastrointestinal tract and decrease stimulation. The client does not need to maintain a daily record of intake and output unless an exacerbation of the disease occurs. A heating pad should not be applied to the intestine as it is inflamed. It is not inevitable that the client will require surgery to treat ulcerative colitis.

5. Which of the following associated disorders may a client with ulcerative colitis exhibit?

Correct answer: D

Rationale: Toxic megacolon is a severe complication that may be exhibited by a client with ulcerative colitis.

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