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. Which area of the alimentary canal is the most common location for Crohn’s disease?

Correct answer: D

Rationale: The terminal ileum is the most common location for Crohn's disease.

3. Which of the following interventions should be included in the medical management of Crohn’s disease?

Correct answer: C

Rationale: Long-term steroid therapy is often used in the management of Crohn's disease to reduce inflammation and suppress the immune response.

4. You’re patient, post-op drainage of a pelvic abscess secondary to diverticulitis, begins to cough violently after drinking water. His wound has ruptured and a small segment of the bowel is protruding. What’s your priority?

Correct answer: D

Rationale: For a patient with a ruptured wound and protruding bowel, call the doctor while remaining with the patient, flex the patient’s knees, and cover the wound with sterile towels soaked in sterile saline solution.

5. The client with cirrhosis has ascites and excess fluid volume. Which measure will the nurse include in the plan of care for this client?

Correct answer: B

Rationale: Excess fluid volume, related to the accumulation of fluid in the peritoneal and dependent areas of the body, can occur in the client with cirrhosis. Fluids should be restricted, including fluids given in medications and meals. Sodium restriction also aids in reducing fluid volume excess.

Similar Questions

A client is scheduled for an abdominal perineal resection with permanent colostomy. Which of the following measures would most likely be included in the plan for the client's preoperative preparation?
Which of the following diets is most commonly associated with colon cancer?
Which of the following nursing measures would be inappropriate when caring for a client with a Cantor tube?
The nurse is performing a colostomy irrigation on a client. During the irrigation, a client begins to complain of abdominal cramps. Which of the following is the most appropriate nursing action?
Which of the following tests is most commonly used to diagnose cholecystitis?

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