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. Your patient has a retractable gastric peptic ulcer and has had a gastric vagotomy. Which factor increases as a result of vagotomy?

Correct answer: D

Rationale: After a gastric vagotomy, the gastric pH increases as a result of reduced acid secretion.

3. Which of the following therapies is not included in the medical management of a client with peritonitis?

Correct answer: D

Rationale: A regular diet is not included in the medical management of peritonitis, which requires bowel rest and IV fluids.

4. You’re caring for a 28 y.o. woman with hepatitis B. She’s concerned about the duration of her recovery. Which response isn’t appropriate?

Correct answer: A

Rationale: Encouraging the patient to not worry about the future is not appropriate. Instead, address her concerns and provide information.

5. 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.

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