the client has had a new colostomy created 2 days earlier the client is beginning to pass malodorous flatus from the stoma the nurse interprets that
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Nursing Elites

ATI RN

Gastrointestinal System Nursing Exam Questions

1. The client has had a new colostomy created 2 days earlier. The client is beginning to pass malodorous flatus from the stoma. The nurse interprets that

Correct answer: B

Rationale: As peristalsis returns following creation of a colostomy, the client begins to pass malodorous flatus. This indicates returning bowel function and is an expected event. Within 72 hours of surgery, the client should begin passing stool via the colostomy.

2. A nurse is reviewing the results of serum laboratory studies drawn on a client who is suspected of having hepatitis. The nurse interprets that an elevation in which of the following studies is the most specific indicator of the disease?

Correct answer: C

Rationale: Laboratory indicators of hepatitis include elevated liver enzymes, serum bilirubin level, and erythrocyte sedimentation rate is nonspecific test that indicates the presence of inflammation somewhere in the body. Elevated blood urea nitrogen may indicate renal dysfunction. A hemoglobin level is unrelated to this diagnosis.

3. Which of the following symptoms best describes Murphy’s sign?

Correct answer: C

Rationale: Murphy's sign is described as pain elicited on deep inspiration when the examiner's fingers are placed under the right costal margin.

4. The client being seen in a physician’s office has just been scheduled for a barium swallow the next day. The nurse writes down which of the following instructions for the client to follow before the test?

Correct answer: A

Rationale: Fasting for 8 hours ensures that the stomach is empty, which is necessary for an accurate barium swallow test.

5. The nurse is irrigating a client's colostomy when she complains of abdominal cramping after receiving about 100 mL of the irrigating solution. What should the nurse's first response be in this situation?

Correct answer: A

Rationale: The abdominal cramping that can occur during colostomy irrigation results from stimulation of the colon by the irrigating solution. The nurse's first response should be to temporarily stop the flow of solution to allow the cramping to subside. Repositioning the client to the right side will not alleviate the cramping. Removing the tube will not decrease the cramping and will necessitate reinsertion of the tube when the irrigation is resumed. Massaging the abdomen gently may be soothing to some clients, but it is not the nurse's first priority action.

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The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis. The client is scheduled for surgery for 2 hours. The client begins to complain of increases abdominal pain and begins to vomit. On assessment the nurse notes that the abdomen distended and bowel sounds are diminished. Which of the following is the most appropriate nursing intervention?

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