the client with a new colostomy is concerned about the odor from stool from the ostomy drainage bag the nurse teaches the client to include which of t
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Nursing Elites

ATI RN

Gastrointestinal System Nursing Exam Questions

1. The client with a new colostomy is concerned about the odor from stool from the ostomy drainage bag. The nurse teaches the client to include which of the following foods in the diet to reduce odor?

Correct answer: A

Rationale: The client should be taught to include deodorizing foods in the diet, such as beet greens, parsley, buttermilk, and yogurt. Spinach also reduces odor but is a gas-forming food as well. Broccoli, cucumber, and eggs are gas-forming foods.

2. A client with viral hepatitis has no appetite, and food makes the client nauseated. Which of the following interventions would be most appropriate?

Correct answer: D

Rationale: If nausea occurs and persists, the client will need to be assessed for fluid and electrolyte imbalance. Explaining to the client that the majority of calories should be eaten in the morning hours is important because nausea occurs most often in the afternoon and evening. Clients should select a diet high in calories because energy is required for healing. Protein increases the workload on the liver. Changes in bilirubin interfere with fat absorption, so low-fat diets are tolerated better.

3. The nurse is caring for a client who has had a gastroscopy. Which of the following symptoms may indicate that the client is developing a complication related to the procedure? Select all that apply.

Correct answer: B

Rationale: A temperature of 100°F, epigastric pain, and hematemesis are signs that may indicate a complication related to the gastroscopy procedure.

4. A nurse is developing a plan of care for a client who will be returning to a nursing unit following a percutaneous transhephatic cholangiogram. The nurse includes which intervention in the postprocedure plan of care?

Correct answer: A

Rationale: Following this procedure, the nurse monitors the client’s vital signs closely for indications of hemorrhage and observes the needle insertion site for bleeding and bile leakage. A sandbag is placed over the insertion site to prevent bleeding. The client is maintained on bedrest, and oral intake is avoided in the immediate postprocedure period in case surgery is necessary to control hemorrhage of bile extravasation.

5. To accurately assess for jaundice in a patient with dark skin pigmentation, the nurse should examine which body areas?

Correct answer: C

Rationale: To accurately assess for jaundice in a patient with dark skin pigmentation, the nurse should examine the hard palate of the mouth. Jaundice is best assessed in the sclera; however, in dark-skinned patients, normal yellow pigmentation may be present in the sclera, making it difficult to detect jaundice. Inspection of the hard palate for a yellow color can confirm the presence of jaundice. Cyanosis is best observed in the nail beds, not indicative of jaundice. While skin on the palm of the hand can indicate jaundice, the back of the hand is not a typical area for assessment. Jaundice can be assessed on the soles of the feet in dark-skinned patients, but it is better visualized in the hard palate for accurate evaluation.

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