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. The nurse is caring for a client following a Billroth II procedure. On review of the post-operative orders, which of the following, if prescribed, would the nurse question and verify?

Correct answer: A

Rationale: Irrigating the nasogastric tube is typically not recommended after a Billroth II procedure unless specifically ordered by a physician due to the risk of disrupting the surgical site.

3. A nurse is assigned to a 40-year-old client who has a diagnosis of chronic pancreatitis. The nurse reviews the laboratory result, anticipating a laboratory report that indicates a serum amylase level of

Correct answer: C

Rationale: The normal serum amylase level is 25 to 151 IU/L. With chronic cases of pancreatitis, the rise in serum amylase levels usually does not exceed three times the normal value. In acute pancreatitis, the value may exceed five times the normal value. Options 1 and 2 are within normal limits. Option 3 is an extremely elevated level seen in acute pancreatitis.

4. The hospitalized client with gastroesophageal reflux disease is complaining of chest discomfort that feels like heartburn following a meal. After administering an ordered antacid, the nurse encourages the client to lie in which of the following positions?

Correct answer: C

Rationale: The discomfort of reflux is aggravated by positions that compress the abdomen and the stomach. Lying flat on the back (supine) or on the stomach (prone) after a meal can exacerbate symptoms. Similarly, lying on the right side can worsen reflux. The most appropriate position to alleviate discomfort in a client with gastroesophageal reflux disease is lying on the left side with the head of the bed elevated at a 30-degree angle. This position helps prevent the backflow of stomach contents into the esophagus, providing relief to the client.

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

Correct answer: B

Rationale: The symptoms suggest possible perforation or peritonitis, which are serious complications requiring immediate medical attention. The nurse should promptly notify the physician.

Similar Questions

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?
The client with a colostomy has an order for irrigation of the colostomy. The nurse used which solution for irrigation?
The client has been admitted with a diagnosis of acute pancreatitis. The nurse would assess this client for pain that is:
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?
The nurse provides medication instructions to a client with peptic ulcer disease. Which statement, if made by the client, indicates the best understanding of the medication therapy?

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