you have to teach ostomy self care to a patient with a colostomy you tell the patient to measure and cut the wafer
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Nursing Elites

ATI RN

ATI Gastrointestinal System Test

1. You have to teach ostomy self care to a patient with a colostomy. You tell the patient to measure and cut the wafer:

Correct answer: C

Rationale: The wafer should be measured and cut about 1/8” larger than the stoma to ensure proper fit and prevent skin irritation.

2. The nurse is caring for a client with chronic gastritis. The nurse monitors the client, knowing that this client is at risk for which of the following vitamin deficiencies?

Correct answer: B

Rationale: Clients with chronic gastritis are at risk for Vitamin B12 deficiency due to impaired absorption.

3. 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.

4. The nurse aspirates 40 mL of undigested formula from the client’s nasogastric tube. Before administering an intermittent tube feeding, the nurse understands that the 40 mL of gastric aspirate should be

Correct answer: B

Rationale: After checking the residual feeding contents, the gastric contents are reinstalled into the stomach by removing the syringe bulb or plunger and pouring the gastric contents into the syringe and through the nasogastric tube. Gastric contents should be reinstalled to maintain the client’s electrolyte balance. The gastric contents should be poured into the nasogastric tube through a syringe without a plunger and not injected by putting pressure on the plunger. Gastric contents do not need to be mixed with water or should the contents be discarded.

5. A client who has had gastrectomy is not producing sufficient intrinsic factor. The nurse interprets that the client has lost the ability to absorb cyanocobalamin (vitamin B12) in the

Correct answer: B

Rationale: Intrinsic factor is produced in the stomach but is used to aid in the absorption of vitamin B12 in the small intestine. Vitamin B12 is not absorbed in the large intestine (options 3 and 4).

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