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. The client is admitted to the hospital with viral hepatitis, complaining of 'no appetite' and 'losing my taste for food.' To provide adequate nutrition, the nurse would instruct the client to

Correct answer: C

Rationale: Although no special diet is required to treat viral hepatitis, it is generally recommended that clients consume a diet with low-fat content because fat may be tolerated poorly due to decreased bile production. Small, frequent meals are preferable and may prevent nausea. Appetite is often better in the morning, so it is easier to eat a good breakfast. An adequate fluid intake of 2500 to 3000 mL per day that includes nutritional juices is also important.

3. The nurse is monitoring a client for the early signs of dumping syndrome. Which symptom indicates this occurrence?

Correct answer: C

Rationale: Sweating and pallor are early signs of dumping syndrome, a condition where food moves too quickly from the stomach to the small intestine.

4. You’re advising a 21 y.o. with a colostomy who reports problems with flatus. What food should you recommend?

Correct answer: D

Rationale: Yogurt can help reduce problems with flatus in patients with a colostomy.

5. 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.

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