your teaching anthony how to use his new colostomy how much skin should remain exposed between the stoma and the ring of the appliance
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Nursing Elites

ATI RN

ATI Gastrointestinal System Test

1. Your teaching Anthony how to use his new colostomy. How much skin should remain exposed between the stoma and the ring of the appliance?

Correct answer: A

Rationale: When teaching a patient how to use a colostomy, only 1/16” of skin should remain exposed between the stoma and the ring of the appliance to prevent skin irritation.

2. Five days after undergoing surgery, a client develops a small-bowel obstruction. A Miller-Abbott tube is inserted for bowel decompression. Which nursing diagnosis takes priority?

Correct answer: C

Rationale: For a client with a small-bowel obstruction and a Miller-Abbott tube, deficient fluid volume is the priority nursing diagnosis.

3. The nurse is caring for a client who has had a gastroscopy. Which of the following symptoms may indicate that the client is developing a complication related to the procedure? Select all that apply.

Correct answer: B

Rationale: A temperature of 100°F, epigastric pain, and hematemesis are signs that may indicate a complication related to the gastroscopy procedure.

4. 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.

5. A client presents to the emergency room, reporting that he has been vomiting every 30 to 40 minutes for the past 8 hours. Frequent vomiting puts him at risk for which of the following?

Correct answer: D

Rationale: Frequent vomiting can lead to metabolic alkalosis with hypokalemia due to the loss of stomach acid and electrolytes.

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