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. Before bowel surgery, Lee is to administer enemas until clear. During administration, he complains of intestinal cramps. What do you do next?

Correct answer: B

Rationale: If a patient complains of intestinal cramps during an enema, lowering the height of the enema container can help reduce discomfort.

3. Sitty, a 66 y.o. patient underwent a colostomy for ruptured diverticulum. She did well during the surgery and returned to your med-surg floor in stable condition. You assess her colostomy 2 days after surgery. Which finding do you report to the doctor?

Correct answer: A

Rationale: A blanched stoma 2 days after colostomy surgery should be reported to the doctor as it may indicate compromised blood flow.

4. Donald is a 61 y.o. man with diverticulitis. Diverticulitis is characterized by:

Correct answer: D

Rationale: Diverticulitis is characterized by crampy lower left quadrant pain and a low-grade fever.

5. A client with ulcerative colitis has an order to begin salicylate medication to reduce inflammation. The nurse instructs the client to take the medication:

Correct answer: C

Rationale: The correct answer is C: After meals. Salicylate medications for ulcerative colitis should be taken after meals to minimize gastrointestinal irritation and enhance absorption. Taking the medication on an empty stomach (Choice B) may increase the risk of gastrointestinal side effects. Taking it 30 minutes before meals (Choice A) may not provide enough protection for the stomach lining. Taking it on arising (Choice D) is not recommended as it may not coincide with the peak absorption times of the medication.

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