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

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?

A. Notify the physician.
B. Change the dressing.
C. Circle the amount on the dressing with a pen.
D. Continue to monitor the drainage.

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 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.

3. Which of the following tests is most commonly used to diagnose cholecystitis?

A. Abdominal CT scan
B. Abdominal ultrasound
C. Barium swallow
D. Endoscopy

Correct answer: B

Rationale: An abdominal ultrasound is the most commonly used test to diagnose cholecystitis.

4. 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.