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. 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.

3. A client with peptic ulcer disease tells the nurse that he has black stools, which he has not reported to his physician. Based on this information, which nursing diagnosis would be appropriate for this client?

Correct answer: B

Rationale: Deficient knowledge related to unfamiliarity with significant signs and symptoms is appropriate because the client did not report the black stools, which can be a sign of bleeding.

4. The client who has undergone creation of a colostomy has a nursing diagnosis of Disturbed body image. The nurse would evaluate that the client is making the most significant progress toward identified goals if the client:

Correct answer: D

Rationale: The correct answer is D: Practices cutting the ostomy appliance. This choice indicates that the client is actively involved in self-care and adapting to the colostomy. By practicing cutting the ostomy appliance, the client is demonstrating independence and self-management skills, showing significant progress towards overcoming the disturbed body image. Choices A, B, and C do not involve active participation in self-care tasks related to the colostomy, which are essential for the client's adaptation and acceptance.

5. Lactulose (Chronulac) is prescribed for a client with a diagnosis of hepatic encephalopathy. The nurse would determine that this medication has had a therapeutic effect if which of the following is noted?

Correct answer: B

Rationale: Lactulose is prescribed for the client with hepatic encephalopathy to reduce bacterial breakdown of protein in the bowel. The medication creates an acidic environment in the bowel and causes the ammonia to leave the bloodstream and enter the colon. Ammonia then becomes trapped in the bowel. Lactulose also has a laxative effect that allows for the elimination of the ammonia.

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