the nurse evaluates the clients stoma during the initial post op period which of the following observations should be reported immediately to the phys
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Nursing Elites

ATI RN

ATI Gastrointestinal System Test

1. The nurse evaluates the client’s stoma during the initial post-op period. Which of the following observations should be reported immediately to the physician?

Correct answer: B

Rationale: A dark red to purple stoma may indicate compromised blood flow or ischemia, which requires immediate medical attention. This color change could be a sign of inadequate blood supply to the stoma tissue, leading to tissue damage or necrosis. Reporting this observation promptly is crucial to prevent further complications. Choices A, C, and D are not indicative of immediate medical concern. A slightly edematous stoma, oozing a small amount of blood, or not expelling stool may not be uncommon findings during the initial post-op period and can be managed without urgent intervention.

2. Which of the following expected outcomes would be most appropriate for a client with peptic ulcer disease? The client will:

Correct answer: A

Rationale: A realistic goal for this client would be to gain relief from epigastric pain. There is no need for vitamin B12 injections because this client has not had any gastric surgery that would lead to vitamin B12 deficiency. Exercise should be modified, not increased, because it can stimulate further production of gastric acid. It is not possible to eliminate stress from a client's life. Instead, the client should be assisted to develop effective coping and problem-solving strategies as necessary.

3. After gastric resection surgery, which of the following signs and symptoms would alert the nurse to the development of a leaking anastomosis?

Correct answer: A

Rationale: Pain, fever, and abdominal rigidity are signs and symptoms of inflammation or peritonitis caused by the leaking anastomosis. Diarrhea with fat in the stool is steatorrhea and is not present in peritonitis. Palpitations, pallor, and diaphoresis after eating are vasomotor symptoms of gastric retention. Feelings of fullness and nausea after eating are not present in peritonitis.

4. Which of the following tests can be used to diagnose ulcers?

Correct answer: D

Rationale: Esophagogastroduodenoscopy (EGD) is a diagnostic test that involves visualizing the esophagus, stomach, and duodenum to diagnose ulcers.

5. A client has been diagnosed with adenocarcinoma of the stomach and is scheduled to undergo a subtotal gastrectomy (Billroth II procedure). During pre-operative teaching, the nurse is reinforcing information about the procedure. Which of the following explanations is most accurate?

Correct answer: B

Rationale: The Billroth II procedure involves anastomosis of the gastric stump to the jejunum.

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