ATI RN
Gastrointestinal System Nursing Exam Questions
1. The client with a colostomy has an order for irrigation of the colostomy. The nurse uses which solution for the irrigation?
- A. Distilled water
- B. Tap water
- C. Sterile water
- D. Lactated Ringer’s
Correct answer: B
Rationale: The correct solution to use for the irrigation of a colostomy is warm tap water or saline solution. If tap water is not suitable for drinking, bottled water can be used. Distilled water, sterile water, and Lactated Ringer’s are not appropriate solutions for colostomy irrigation. Distilled water lacks essential minerals, sterile water may not provide adequate cleaning, and Lactated Ringer’s is not indicated for this procedure.
2. A nurse is caring for a client who has just returned from the operating room following the creation of a colostomy. The nurse is assessing the drainage in the pouch attached to the site where the colostomy was formed and notes serosanguineous drainage. Which nursing action is most appropriate based on this assessment?
- A. Notify the physician
- B. Document the amount and characteristics of the drainage
- C. Apply ice to the stoma site
- D. Apply pressure to the site
Correct answer: B
Rationale: During the first 24 to 72 hours following surgery, mucus and serosanguineous drainage are expected from the stoma. Documenting the amount and characteristics of the drainage is appropriate. The nurse does not need to notify the physician because this is an expected finding. Applying ice or pressure to the site is not necessary.
3. The nurse is preparing a discharge teaching plan for the client who had an umbilical hernia repair. Which of the following would the nurse include in the plan?
- A. Restricting pain medication
- B. Maintaining bedrest
- C. Avoiding coughing
- D. Irrigating the drain
Correct answer: C
Rationale: To prevent strain on the surgical site and avoid disruption of tissue integrity, the client should avoid coughing after an umbilical hernia repair.
4. Your patient recently had abdominal surgery and tells you that he feels a popping sensation in his incision during a coughing spell, followed by severe pain. You anticipate an evisceration. Which supplies should you take to his room?
- A. A suture kit.
- B. Sterile water and a suture kit.
- C. Sterile water and sterile dressings.
- D. Sterile saline solution and sterile dressings.
Correct answer: D
Rationale: For a suspected evisceration, sterile saline solution and sterile dressings should be taken to the patient's room to cover the wound and keep it moist.
5. Which of the following therapies is not included in the medical management of a client with peritonitis?
- A. Broad-spectrum antibiotics
- B. Electrolyte replacement
- C. I.V. fluids
- D. Regular diet
Correct answer: D
Rationale: A regular diet is not included in the medical management of peritonitis, which requires bowel rest and IV fluids.
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