ATI RN
ATI Gastrointestinal System Quizlet
1. 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:
- A. Watches the nurse empty the colostomy bag
- B. Looks at the ostomy site
- C. Reads the ostomy product literature
- D. Practices cutting the ostomy appliance
Correct answer: D
Rationale: The correct answer is D: Practices cutting the ostomy appliance. This choice indicates that the client is actively involved in self-care and adapting to the colostomy. By practicing cutting the ostomy appliance, the client is demonstrating independence and self-management skills, showing significant progress towards overcoming the disturbed body image. Choices A, B, and C do not involve active participation in self-care tasks related to the colostomy, which are essential for the client's adaptation and acceptance.
2. The nurse is caring for a client admitted to the hospital with a suspected diagnosis of acute appendicitis. Which of the following laboratory results would the nurse expect to note if the client indeed has appendicitis?
- A. Leukopenia with a shift to the right
- B. Leukocytosis with a shift to the right
- C. Leukocytosis with a shift to the left
- D. Leukopenia with a shift to the left
Correct answer: C
Rationale: Laboratory findings do not establish the diagnosis of appendicitis, but often moderate elevation of the white blood cell count (leukocytosis) to 10,000 to 18,000 cells/mm3 occurs with a “shift to the left” (an increased number of immature white blood cells.).
3. The client with GERD complains of a chronic cough. The nurse understands that in a client with GERD this symptom may be indicative of which of the following conditions?
- A. Development of laryngeal cancer
- B. Irritation of the esophagus
- C. Esophageal scar tissue formation
- D. Aspiration of gastric contents
Correct answer: D
Rationale: Aspiration of gastric contents can lead to a chronic cough in clients with GERD.
4. Gail is scheduled for a cholecystectomy. After completion of preoperative teaching, Gail states,”If I lie still and avoid turning after the operation, I’ll avoid pain. Do you think this is a good idea?” What is the best response?
- A. You’ll need to turn from side to side every 2 hours.
- B. It’s always a good idea to rest quietly after surgery.
- C. The doctor will probably order you to lie flat for 24 hours.
- D. Why don’t you decide about activity after you return from the recovery room?
Correct answer: A
Rationale: The best response to Gail is to inform her that she will need to turn from side to side every 2 hours to prevent complications.
5. You’re patient, post-op drainage of a pelvic abscess secondary to diverticulitis, begins to cough violently after drinking water. His wound has ruptured and a small segment of the bowel is protruding. What’s your priority?
- A. Ask the patient what happened, call the doctor, and cover the area with a water-soaked bedsheet.
- B. Obtain vital signs, call the doctor, and obtain emergency orders.
- C. Have a CAN hold the wound together while you obtain vital signs, call the doctor and flex the patient’s knees.
- D. Have the doctor called while you remain with the patient, flex the patient’s knees, and cover the wound with sterile towels soaked in sterile saline solution.
Correct answer: D
Rationale: For a patient with a ruptured wound and protruding bowel, call the doctor while remaining with the patient, flex the patient’s knees, and cover the wound with sterile towels soaked in sterile saline solution.
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