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

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?

A. Notify the physician
B. Document the amount and characteristics of the drainage
C. Apply ice to the stoma site
D. Apply pressure to the site

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. Claire, a 33 y.o. is on your floor with a possible bowel obstruction. Which intervention is priority for her?

A. Obtain daily weights.
B. Measure abdominal girth.
C. Keep strict intake and output.
D. Encourage her to increase fluids.

Correct answer: B

Rationale: For a patient with a possible bowel obstruction, measuring abdominal girth is a priority to monitor for signs of worsening obstruction or distention.

3. A client with suspected gastric cancer undergoes an endoscopy of the stomach. Which of the following assessments made after the procedure would indicate the development of a potential complication?

A. The client complains of a sore throat
B. The client displays signs of sedation
C. The client experiences a sudden increase in temperature
D. The client demonstrates a lack of appetite

Correct answer: C

Rationale: A sudden increase in temperature after an endoscopy can indicate a potential complication, such as perforation.

4. The client with cirrhosis has ascites and excess fluid volume. Which measure will the nurse include in the plan of care for this client?

A. Increase the amount of sodium in the diet.
B. Limit the amount of fluids consumed.
C. Encourage frequent ambulation.
D. Administer magnesium antacids.

Correct answer: B

Rationale: Excess fluid volume, related to the accumulation of fluid in the peritoneal and dependent areas of the body, can occur in the client with cirrhosis. Fluids should be restricted, including fluids given in medications and meals. Sodium restriction also aids in reducing fluid volume excess.