sitty a 66 yo patient underwent a colostomy for ruptured diverticulum she did well during the surgery and returned to your med surg floor in stable co
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Nursing Elites

ATI RN

ATI Gastrointestinal System Test

1. Sitty, a 66 y.o. patient underwent a colostomy for ruptured diverticulum. She did well during the surgery and returned to your med-surg floor in stable condition. You assess her colostomy 2 days after surgery. Which finding do you report to the doctor?

Correct answer: A

Rationale: A blanched stoma 2 days after colostomy surgery should be reported to the doctor as it may indicate compromised blood flow.

2. Before administering an intermittent tube feeding through a nasogastric tube, the nurse assesses for gastric residual. The nurse understands that this procedure is important to

Correct answer: D

Rationale: Evaluating the absorption of the last feeding is important because administration of a tube feeding to a full stomach could result in overdistention, thus predisposing the client to regurgitation and possible aspiration.

3. The hospitalized client with GERD is complaining of chest discomfort that feels like heartburn following a meal. After administering an ordered antacid, the nurse encourages the client to lie in which of the following positions?

Correct answer: C

Rationale: Lying on the left side with the head of the bed elevated 30 degrees helps prevent reflux by keeping stomach contents from moving up into the esophagus.

4. The nurse is teaching the client how to perform a colostomy irrigation. To enhance the effectiveness of the irrigation and fecal returns, what measure should the nurse instruct the client to do?

Correct answer: A

Rationale: Increasing fluid intake helps to enhance the effectiveness of colostomy irrigation by softening the stool and promoting better fecal return.

5. The nurse is monitoring a client for the early signs and symptoms for dumping syndrome. Which symptom indicates this occurrence?

Correct answer: C

Rationale: Early manifestations of dumping syndrome occur 5 to 30 minutes after eating. Symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down.

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