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. Donald is a 61 y.o. man with diverticulitis. Diverticulitis is characterized by:

Correct answer: D

Rationale: Diverticulitis is characterized by crampy lower left quadrant pain and a low-grade fever.

3. The client with ascites is scheduled for a paracentesis. The nurse is assisting the physician in performing the procedure. Which of the following positions will the nurse assist the client to assume for this procedure?

Correct answer: D

Rationale: An upright position allows the intestine to float posteriorly and helps prevent intestinal laceration during catheter insertion.

4. Which of the following activities should the nurse encourage the client with a peptic ulcer to avoid?

Correct answer: B

Rationale: Cigarette smoking should be avoided because of its stimulatory effect on gastric secretions. Nicotine also increases the release of epinephrine, which leads to vasoconstriction. The client may chew gum if desired. The client may eat chocolate if desired. A client with a peptic ulcer should check with the physician before taking any over-the-counter drug, but acetaminophen does not typically cause gastric irritation.

5. Sharon has cirrhosis of the liver and develops ascites. What intervention is necessary to decrease the excessive accumulation of serous fluid in her peritoneal cavity?

Correct answer: A

Rationale: Restricting fluids is necessary to decrease the excessive accumulation of serous fluid in the peritoneal cavity for a patient with ascites due to cirrhosis.

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