the nurse is irrigating a clients colostomy when she complains of abdominal cramping after receiving about 100 ml of the irrigating solution what shou
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Nursing Elites

ATI RN

Gastrointestinal System Nursing Exam Questions

1. The nurse is irrigating a client's colostomy when she complains of abdominal cramping after receiving about 100 mL of the irrigating solution. What should the nurse's first response be in this situation?

Correct answer: A

Rationale: The abdominal cramping that can occur during colostomy irrigation results from stimulation of the colon by the irrigating solution. The nurse's first response should be to temporarily stop the flow of solution to allow the cramping to subside. Repositioning the client to the right side will not alleviate the cramping. Removing the tube will not decrease the cramping and will necessitate reinsertion of the tube when the irrigation is resumed. Massaging the abdomen gently may be soothing to some clients, but it is not the nurse's first priority action.

2. The client has been admitted with a diagnosis of acute pancreatitis. The nurse would assess this client for pain that is:

Correct answer: A

Rationale: Acute pancreatitis typically presents with severe, unrelenting pain in the epigastric area that radiates to the back. This pain is due to inflammation and autodigestion of the pancreas.

3. The nurse is caring for a client with cirrhosis. Which manifestations indicate deficient vitamin K absorption caused by this liver disease?

Correct answer: C

Rationale: A liver disorder, such as cirrhosis, can disrupt the liver's normal use of vitamin K to produce prothrombin (a clotting factor). Because of this, the nurse should monitor the client for signs of bleeding, including purpura and petechiae. Dyspnea and fatigue suggest anemia. Ascites and orthopnea are unrelated to vitamin K absorption. Gynecomastia and testicular atrophy result from decreased estrogen metabolism by the diseased liver.

4. The student nurse is teaching the family of a patient with liver failure. You instruct them to limit which foods in the patient’s diet?

Correct answer: A

Rationale: For a patient with liver failure, it is important to limit the intake of meats and beans to reduce the risk of hepatic encephalopathy.

5. A client with gastric cancer can expect to have surgery for resection. Which of the following should be the nursing management priority for the preoperative client with gastric cancer?

Correct answer: B

Rationale: The priority for preoperative management of a client with gastric cancer is the correction of nutritional deficits.

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