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 nurse is doing pre-op teaching with the client who is about to undergo creation of a Kock pouch. The nurse interprets that the client has the best understanding of the nature of the surgery if the client makes which of the following statements?

Correct answer: A

Rationale: A Kock pouch is a type of continent ileostomy that requires catheterization to empty the internal reservoir. Understanding the need for regular catheterization indicates the client comprehends the procedure.

3. A female client complains of gnawing epigastric pain for a few hours after meals. At times, when the pain is severe, vomiting occurs. Specific tests are indicated to rule out:

Correct answer: A

Rationale: Specific tests are indicated to rule out cancer of the stomach when a client complains of gnawing epigastric pain and vomiting after meals.

4. A client is taking an antacid for treatment of a peptic ulcer. Which of the following statements best indicates that the client understands how to correctly take the antacid?

Correct answer: D

Rationale: It is best for the client to take the antacid 1 to 3 hours after meals to ensure effectiveness.

5. Your teaching Anthony how to use his new colostomy. How much skin should remain exposed between the stoma and the ring of the appliance?

Correct answer: A

Rationale: When teaching a patient how to use a colostomy, only 1/16” of skin should remain exposed between the stoma and the ring of the appliance to prevent skin irritation.

Similar Questions

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Which of the following nursing interventions should be implemented to manage a client with appendicitis?
A client is scheduled for oral cholecystography. Which one of the following actions would the nurse plan to implement before the test?
The nurse is assessing for stoma prolapse in a client with a colostomy. The nurse would observe which of the following if stoma prolapse occurred?

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