the client with a colostomy has an order for irrigation of the colostomy the nurse used which solution for irrigation
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Nursing Elites

ATI RN

ATI Gastrointestinal System Quizlet

1. The client with a colostomy has an order for irrigation of the colostomy. The nurse used which solution for irrigation?

Correct answer: B

Rationale: Tap water at body temperature is generally used for colostomy irrigation unless the local water supply is not safe for drinking, in which case bottled water can be used.

2. A client is scheduled for an abdominal perineal resection with permanent colostomy. Which of the following measures would most likely be included in the plan for the client's preoperative preparation?

Correct answer: B

Rationale: Antibiotics are administered preoperatively to reduce the bacterial count in the colon. The client will be placed on a low residue diet to help cleanse the bowel before surgery but typically is not placed on NPO status until 8 to 12 hours before surgery. Laxatives and enemas may also be administered. Chest tubes would not be expected postoperatively. There is no need to limit the client's activity before surgery.

3. The student nurse is teaching the family of a patient with liver failure. You instruct them to limit which foods in the patient’s diet?

Correct answer: A

Rationale: For a patient with liver failure, it is important to limit the intake of meats and beans to reduce the risk of hepatic encephalopathy.

4. A nurse is preparing to remove a nasogastric tube from a client. The nurse would instruct the client to do which of the following just before the nurse removes the tube?

Correct answer: B

Rationale: When the nurse removes a nasogastric tube, the client is instructed to take and hold a deep breath. This will be obstructed temporarily during the tube removal. This allows for easy withdrawal through the esophagus into the nose. The nurse removes the tube with one smooth, continuous pull.

5. The client with cirrhosis has ascites and excess fluid volume. Which measure will the nurse include in the plan of care for this client?

Correct answer: B

Rationale: Excess fluid volume, related to the accumulation of fluid in the peritoneal and dependent areas of the body, can occur in the client with cirrhosis. Fluids should be restricted, including fluids given in medications and meals. Sodium restriction also aids in reducing fluid volume excess.

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