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. A patient has an acute upper GI hemorrhage. Your interventions include:

Correct answer: D

Rationale: For a patient with an acute upper GI hemorrhage, your interventions include treating shock and diagnosing the bleeding source.

3. The nurse is assessing a 71-year-old female client with ulcerative colitis. Which assessment finding related to the family will have the greatest impact on the client's rehabilitation after discharge?

Correct answer: C

Rationale: Emotional support from the family is the main need. A special diet doesn't focus on emotional needs. Role expectations don't address the main issue, but emotional support while the client is fulfilling these roles is important. The family's ability to understand the ups and downs of the illness will help them but not the client.

4. A nurse is performing an assessment on a client with a suspected diagnosis of acute pancreatitis. The nurse assesses the client, knowing that which of the following is a hallmark sign of this disorder?

Correct answer: B

Rationale: A hallmark sign of acute pancreatitis is severe abdominal pain that is not relieved by vomiting. Nausea and vomiting are common presenting symptoms, with vomitus typically consisting of gastric and duodenal contents. Hypothermia is not a hallmark sign of acute pancreatitis. Fever, typically less than 38 degrees centigrade, is more common. Epigastric pain radiating to the neck area is not a characteristic sign of acute pancreatitis. Therefore, choice B is the correct answer.

5. A nurse is inserting a nasogastric tube in an adult client. During the procedure, the client begins to cough and has difficulty breathing. Which of the following is the most appropriate nursing action?

Correct answer: B

Rationale: During the insertion of a nasogastric tube, if the client experiences difficulty breathing or any respiratory distress, withdraw the tube slightly, stop the tube advancement, and wait until the distress subsides. Options 1 and 4 are unnecessary. Quickly inserting the tube is not an appropriate action because, in this situation, it may be likely that the tube has entered the bronchus.

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Claire, a 33 y.o. is on your floor with a possible bowel obstruction. Which intervention is priority for her?
The client who has undergone creation of a colostomy has a nursing diagnosis of Disturbed body image. The nurse would evaluate that the client is making the most significant progress toward identified goals if the client:
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