youre assessing the stoma of a patient with a healthy well healed colostomy you expect the stoma to appear
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Nursing Elites

ATI RN

ATI Gastrointestinal System Test

1. You’re assessing the stoma of a patient with a healthy, well-healed colostomy. You expect the stoma to appear:

Correct answer: B

Rationale: A healthy, well-healed colostomy stoma should appear red and moist.

2. Which of the following tasks should be included in the immediate postoperative management of a client who has undergone gastric resection?

Correct answer: D

Rationale: Monitoring for symptoms of hemorrhage is a crucial part of the immediate postoperative management of a client who has undergone gastric resection.

3. A client with a peptic ulcer reports epigastric pain that frequently awakens her at night, a feeling of fullness in the abdomen, and a feeling of anxiety about her health. Based on this information, which nursing diagnosis would be most appropriate?

Correct answer: B

Rationale: Disturbed Sleep Pattern related to epigastric pain is appropriate because the client reports pain that frequently awakens her at night.

4. The nurse is teaching the client how to perform a colostomy irrigation. To enhance the effectiveness of the irrigation and fecal returns, what measure should the nurse instruct the client to do?

Correct answer: A

Rationale: Increasing fluid intake helps to enhance the effectiveness of colostomy irrigation by softening the stool and promoting better fecal return.

5. The nurse is doing preoperative teaching with the client who is about to undergo creation of a Kock pouch. The nurse interprets that the client has the best understanding of the nature of the surgery if the client makes which of the following statements?

Correct answer: A

Rationale: A Kock pouch is a continent ileostomy. As the ileostomy begins to function, the client drains it every 3 to 4 hours and then decreases the draining about 3 times a day or as needed when full. The client does not need to wear a drainage bag but should wear an absorbent dressing to absorb mucous drainage from the stoma. Ileostomy drainage is liquid. The client would be able to pass stool only from the rectum if an ileal-anal pouch or anastomosis were created. This type of operation is a two-stage procedure.

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