a penrose drain is in place on the first postoperative day following a cholecystectomy serosanguineous drainage is noted on the dressing covering the
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Nursing Elites

ATI RN

Gastrointestinal System Nursing Exam Questions

1. A Penrose drain is in place on the first postoperative day following a cholecystectomy. Serosanguineous drainage is noted on the dressing covering the drain. Which nursing intervention is most appropriate?

Correct answer: B

Rationale: Serosanguineous drainage with a small amount of bile is expected from the Penrose drain for the first 24 hours. Drainage then decreases, and the drain is removed usually within 48 hours. The nurse does not need to notify the physician. A sterile dressing covers the site and should be changed to prevent infection and skin excoriation.

2. A client with ulcerative colitis is diagnosed with a mild case of the disease. The nurse doing dietary teaching gives the client examples of foods to eat that represent which of the following therapeutic diets?

Correct answer: C

Rationale: The client with a mild case of ulcerative colitis is often advised to follow a diet low in roughage and avoid milk. This dietary approach helps reduce the frequency of diarrhea in these clients. Therefore, the correct therapeutic diet for the client with ulcerative colitis in this scenario is a low-roughage diet without milk. Choices A, B, and D are incorrect because high-fat, high-protein, and low-roughage with milk diets are not typically recommended for clients with ulcerative colitis, especially those with mild cases.

3. Which of the following nursing interventions should have the highest priority during the first hour after the admission of a client with cholecystitis who is experiencing pain, nausea, and vomiting?

Correct answer: A

Rationale: Administering pain medication would have the highest priority during the first hour after the client's admission. Pain relief is essential to address the client's immediate discomfort and distress. Completing the admission history, maintaining hydration, and teaching about planned diagnostic tests are important aspects of care but can be addressed after addressing the client's pain and stabilizing their condition.

4. Nathaniel has severe pruritus due to having hepatitis B. What is the best intervention for his comfort?

Correct answer: A

Rationale: Giving tepid baths can help soothe severe pruritus due to hepatitis B.

5. A nurse is developing a teaching plan for the client with viral hepatitis. The nurse plans to tell the client which of the following in the teaching session?

Correct answer: A

Rationale: The client with viral hepatitis should limit activity to avoid fatigue during the recuperation period. The diet should be optimal in calories, proteins, and carbohydrates. The client should take in several small meals per day. Alcohol is strictly forbidden.

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A client has a percutaneous endoscopic gastrostomy tube inserted for tube feedings. Before starting a continuous feeding, the nurse should place the client in which position?
A client with viral hepatitis has no appetite, and food makes the client nauseated. Which of the following interventions would be most appropriate?
The nurse has inserted a nasogastric tube to the level of the oropharynx and has repositioned the client’s head in a flexed-forward position. The client has been asked to begin swallowing. The nurse starts slowly to advance the nasogastric tube with each swallow. The client begins to cough, gag, and choke. Which nursing action would least likely result in proper tube insertion and promote client relaxation?
To prevent gastroesophageal reflux in a client with hiatal hernia, the nurse should provide which discharge instructions?

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