a client returns from surgery with a sigmoid colostomy an ostomy appliance is attached the priority nursing diagnosis for daily observation and care i
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Nursing Elites

ATI RN

Gastrointestinal System Nursing Exam Questions

1. A client returns from surgery with a sigmoid colostomy. An ostomy appliance is attached. The priority nursing diagnosis for daily observation and care is:

Correct answer: B

Rationale: Impaired skin integrity would be the priority nursing diagnosis for daily care of the colostomy because the effluent from the colostomy can be irritating to the skin. Diarrhea isn't a concern at this point. The client will be allowed nothing by mouth until peristalsis returns. The client should get out of bed on the first postoperative day, so mobility shouldn't be a problem.

2. 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: B

Rationale: Providing skin care following bowel movements, maintaining intake and output records, and obtaining the client's weight can be delegated to a unlicensed assistant.

3. A nurse is giving dietary instructions to a client who has a new colostomy. The nurse encourages the client to eat foods representing which of the following diets for the first 4 to 6 weeks postoperatively?

Correct answer: D

Rationale: For the first 4 to 6 weeks following colostomy formation, the client should take in a low-residue diet. Following this period, the client should eat a high-carbohydrate, high-protein diet. The nurse also instructs the client to add new foods, one at a time, to determine tolerance to that food.

4. An enema is prescribed for a client with suspected appendicitis. Which of the following actions should the nurse take?

Correct answer: B

Rationale: An enema is contraindicated in clients with suspected appendicitis because it can increase the risk of perforation. It is important to verify the appropriateness of this order with the physician.

5. Arthur has a family history of colon cancer and is scheduled to have a sigmoidoscopy. He is crying as he tells you, “I know that I have colon cancer, too.” Which response is most therapeutic?

Correct answer: B

Rationale: Acknowledging the patient's emotions with 'You seem upset' is the most therapeutic response.

Similar Questions

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Annebell is being discharged with a colostomy, and you’re teaching her about colostomy care. Which statement correctly describes a healthy stoma?
To prevent gastroesophageal reflux in a client with hiatal hernia, the nurse should provide which discharge instructions?
The nurse has given instructions to the client with an ileostomy about foods to eat to thicken the stool. The nurse determines that the client needs further instructions if the client stated to eat which of the following foods to make the stools less watery?
You’re developing the plan of care for a patient experiencing dumping syndrome after a Billroth II procedure. Which dietary instructions do you include?

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