youre caring for carin who has just had ileostomy surgery during the first 24 hours post op how much drainage can you expect from the ileostomy
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Nursing Elites

ATI RN

ATI Gastrointestinal System Test

1. You’re caring for Carin who has just had ileostomy surgery. During the first 24 hours post-op, how much drainage can you expect from the ileostomy?

Correct answer: C

Rationale: During the first 24 hours post-op, you can expect about 1500 ml of drainage from the ileostomy.

2. A client returns from surgery with a sigmoid colostomy. An ostomy appliance is attached. The priority nursing diagnosis for daily observation and care is:

Correct answer: B

Rationale: Impaired skin integrity would be the priority nursing diagnosis for daily care of the colostomy because the effluent from the colostomy can be irritating to the skin. Diarrhea isn't a concern at this point. The client will be allowed nothing by mouth until peristalsis returns. The client should get out of bed on the first postoperative day, so mobility shouldn't be a problem.

3. When preparing the client with hepatitis A for extended convalescence, the nurse teaches the client about problems that may occur. The nurse knows that the client has understood the teaching when he says that he is most likely to have difficulty:

Correct answer: D

Rationale: Convalescence after hepatitis A may take weeks or even months. Boredom and depression are common problems that the client should anticipate. Abdominal pain is not usually a symptom of hepatitis A. Maintaining a regular bowel elimination pattern is not usually a problem with hepatitis. Problems preventing respiratory complications are unlikely. To support healing, activity is strictly limited but bed rest is not prescribed.

4. A home care nurse is visiting a client with a diagnosis of pernicious anemia that developed as a result of gastric surgery. The nurse instructs the client that because the stomach lining produces a decreased amount of intrinsic factor in this disorder, the client will need

Correct answer: A

Rationale: A lack of the intrinsic factor needed to absorb vitamin B12 occurs in pernicious anemia. Vitamin B12 is needed for the maturation of red blood cells. Vitamin B6 is not necessarily needed for pernicious anemia and can be taken orally. An antibiotic and antacids may be prescribed for certain types of gastric ulcers.

5. Of the following signs and symptoms of bowel obstruction, which is related primarily to small bowel obstruction rather than large bowel obstruction?

Correct answer: A

Rationale: Profuse vomiting is the classic sign of small bowel obstruction and rarely occurs with large bowel obstruction. Abdominal discomfort and distention are present in both small and large bowel obstructions, but distention is more common in large bowel obstruction. High-pitched bowel sounds indicate hyperperistalsis, which occurs early in obstruction.

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