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 aspects is the priority focus of nursing management for a client with peritonitis?

Correct answer: A

Rationale: The priority focus of nursing management for a client with peritonitis is fluid and electrolyte balance to prevent shock.

3. Which of the following nursing measures would be inappropriate when caring for a client with a Cantor tube?

Correct answer: D

Rationale: Intestinal tubes are not irrigated. Injecting air into the tube, applying water-soluble lubricant, and coiling extra tubing are appropriate nursing measures.

4. Your patient has a retractable gastric peptic ulcer and has had a gastric vagotomy. Which factor increases as a result of vagotomy?

Correct answer: D

Rationale: After a gastric vagotomy, the gastric pH increases as a result of reduced acid secretion.

5. A client is admitted with a diagnosis of ulcerative colitis. Which of the following symptoms should the nurse expect the client to report when responding to questions about his bowel elimination pattern?

Correct answer: B

Rationale: Diarrhea is the primary symptom of ulcerative colitis. It is profuse and severe; the client may pass as many as 15 to 20 watery stools per day. Stools may contain blood, mucus, and pus. The frequent diarrhea is often accompanied by anorexia and nausea. Constipation is not a sign or symptom of ulcerative colitis. Steatorrhea (fatty stools) is more typical of pancreatitis and cholecystitis. Alternating diarrhea and constipation is associated with irritable bowel syndrome.

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