ATI RN
Gastrointestinal System Nursing Exam Questions Questions
Question 1 of 5
The client with a colostomy has an order for irrigation of the colostomy. The nurse uses which solution for the irrigation?
Correct Answer: B
Rationale: The correct solution to use for the irrigation of a colostomy is warm tap water or saline solution. If tap water is not suitable for drinking, bottled water can be used. Distilled water, sterile water, and Lactated Ringer's are not appropriate solutions for colostomy irrigation. Distilled water lacks essential minerals, sterile water may not provide adequate cleaning, and Lactated Ringer's is not indicated for this procedure.
Question 2 of 5
A nurse orientee is preparing to insert a nasogastric tube, and a nurse educator is observing the procedure. Which of the following supplies if obtained by the nurse orientee would indicate a need for further education regarding this procedure?
Correct Answer: B
Rationale: Water-soluble lubricant is used to lubricate 3 to 4 inches of the tube at the insertion end. An oil lubricant is not used because if the tube accidentally goes into the bronchus, pneumonia can develop. Half-inch tape is used to secure the tube after the correct placement is verified. A 50-mL catheter tip syringe is used to aspirate gastric contents to confirm placement. The client will be asked to take a sip of water through a straw to help with the passage of the tube.
Question 3 of 5
The client with a colostomy has an order for irrigation of the colostomy. The nurse uses which solution for the irrigation?
Correct Answer: B
Rationale: The correct solution to use for the irrigation of a colostomy is warm tap water or saline solution. If tap water is not suitable for drinking, bottled water can be used. Distilled water, sterile water, and Lactated Ringer's are not appropriate solutions for colostomy irrigation. Distilled water lacks essential minerals, sterile water may not provide adequate cleaning, and Lactated Ringer's is not indicated for this procedure.
Question 4 of 5
A nurse is developing a plan of care for a client who will be returning to a nursing unit following a percutaneous transhephatic cholangiogram. The nurse includes which intervention in the postprocedure plan of care?
Correct Answer: A
Rationale: Following this procedure, the nurse monitors the client's vital signs closely for indications of hemorrhage and observes the needle insertion site for bleeding and bile leakage. A sandbag is placed over the insertion site to prevent bleeding. The client is maintained on bedrest, and oral intake is avoided in the immediate postprocedure period in case surgery is necessary to control hemorrhage of bile extravasation.
Question 5 of 5
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.
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