your teaching anthony how to use his new colostomy how much skin should remain exposed between the stoma and the ring of the appliance
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Nursing Elites

ATI RN

ATI Gastrointestinal System Test

1. Your teaching Anthony how to use his new colostomy. How much skin should remain exposed between the stoma and the ring of the appliance?

Correct answer: A

Rationale: When teaching a patient how to use a colostomy, only 1/16” of skin should remain exposed between the stoma and the ring of the appliance to prevent skin irritation.

2. After an abdominal resection for colon cancer, Madeline returns to her room with a Jackson-Pratt drain in place. The purpose of the drain is to:

Correct answer: D

Rationale: The purpose of the Jackson-Pratt drain is to prevent the accumulation of drainage in the wound after an abdominal resection.

3. A nurse is caring for a client who has just returned from the operating room following the creation of a colostomy. The nurse is assessing the drainage in the pouch attached to the site where the colostomy was formed and notes serosanguineous drainage. Which nursing action is most appropriate based on this assessment?

Correct answer: B

Rationale: During the first 24 to 72 hours following surgery, mucus and serosanguineous drainage are expected from the stoma. Documenting the amount and characteristics of the drainage is appropriate. The nurse does not need to notify the physician because this is an expected finding. Applying ice or pressure to the site is not necessary.

4. Rob is a 46 y.o. admitted to the hospital with a suspected diagnosis of Hepatitis B. He’s jaundiced and reports weakness. Which intervention will you include in his care?

Correct answer: D

Rationale: For a patient with hepatitis B who is jaundiced and reports weakness, providing rest periods after small, frequent meals is important.

5. 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.

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