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. The nurse assesses the client's understanding of the relationship between body position and gastroesophageal reflux. Which response would indicate that the client understands measures to avoid problems with reflux while sleeping?

Correct answer: D

Rationale: Sleeping with the head of the bed elevated encourages movement of food through the esophagus by gravity. By fostering esophageal acid clearance, gravity helps keep the acidic pepsin and alkaline biliary secretions from contacting the esophagus. Elevating the foot of the bed does not affect clearance of esophageal acid. Sleeping on the stomach with the head turned to the left will not decrease reflux incidence. Sleeping flat without a pillow under the head does not enhance clearance.

3. Which of the following symptoms may be exhibited by a client with Crohn’s disease?

Correct answer: D

Rationale: Clients with Crohn's disease may exhibit symptoms such as steatorrhea, which is the presence of excess fat in the stool.

4. The client with ascites is scheduled for a paracentesis. The nurse is assisting the physician in performing the procedure. Which of the following positions will the nurse assist the client to assume for this procedure?

Correct answer: D

Rationale: An upright position allows the intestine to float posteriorly and helps prevent intestinal laceration during catheter insertion.

5. While caring for a client with peptic ulcer disease, the client reports that he has been nauseated most of the day and is now feeling lightheaded and dizzy. Based upon these findings, which nursing actions would be most appropriate for the nurse to take?

Correct answer: B

Rationale: Monitoring the client's vital signs and notifying the physician of the client's symptoms are crucial actions based on the reported symptoms.

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