a nurse is caring for a client who has just returned from the operating room following the creation of a colostomy the nurse is assessing the drainage
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Nursing Elites

ATI RN

Gastrointestinal System Nursing Exam Questions

1. A nurse is caring for a client who has just returned from the operating room following the creation of a colostomy. The nurse is assessing the drainage in the pouch attached to the site where the colostomy was formed and notes serosanguineous drainage. Which nursing action is most appropriate based on this assessment?

Correct answer: B

Rationale: During the first 24 to 72 hours following surgery, mucus and serosanguineous drainage are expected from the stoma. Documenting the amount and characteristics of the drainage is appropriate. The nurse does not need to notify the physician because this is an expected finding. Applying ice or pressure to the site is not necessary.

2. Which of the following complications is thought to be the most common cause of appendicitis?

Correct answer: A

Rationale: A fecalith is a hardened stool that can block the appendix, leading to inflammation and infection, which is the most common cause of appendicitis.

3. Which of the following interventions should be included in the medical management of Crohn’s disease?

Correct answer: C

Rationale: Long-term steroid therapy is often used in the management of Crohn's disease to reduce inflammation and suppress the immune response.

4. After gastric resection surgery, which of the following signs and symptoms would alert the nurse to the development of a leaking anastomosis?

Correct answer: A

Rationale: Pain, fever, and abdominal rigidity are signs and symptoms of inflammation or peritonitis caused by the leaking anastomosis. Diarrhea with fat in the stool is steatorrhea and is not present in peritonitis. Palpitations, pallor, and diaphoresis after eating are vasomotor symptoms of gastric retention. Feelings of fullness and nausea after eating are not present in peritonitis.

5. The most important pathophysiologic factor contributing to the formation of esophageal varices is:

Correct answer: C

Rationale: Portal hypertension is the most important pathophysiologic factor contributing to the formation of esophageal varices.

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