Nursing Elites

1. A client has a nasogastric tube inserted at the time of abdominal perineal resection with permanent colostomy. This tube will most likely be removed when the client demonstrates:

• A. Absence of nausea and vomiting.
• B. Passage of mucus from the rectum.
• C. Passage of flatus and feces from the colostomy.
• D. Absence of stomach drainage for 24 hours.

Correct answer: C

Rationale: A sign indicating that a client's colostomy is open and ready to function is passage of feces and flatus. When this occurs, gastric suction is ordinarily discontinued, and the client is allowed to start taking fluids and food orally. Absence of bowel sounds would indicate that the tube should remain in place because peristalsis has not yet returned. Absence of nausea and vomiting is not a criterion for judging whether or not gastric suction should be continued. Passage of mucus from the rectum will not occur in this client because the rectum is removed in this surgery. Absence of stomach drainage is not a criterion for judging whether or not gastric suction should be continued.

2. During the first few days of recovery from ostomy surgery for ulcerative colitis, which of the following aspects should be the first priority of client care?

• A. Body image
• B. Ostomy care
• C. Sexual concerns
• D. Skin care

Correct answer: D

Rationale: During the initial recovery period from ostomy surgery, skin care is the first priority to prevent irritation and infection around the stoma site.

3. 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?

• A. 100 ml
• B. 500 ml
• C. 1500 ml
• D. 5000 ml

Correct answer: C

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

4. The client is admitted to the hospital for treatment of acute hepatitis B. Which activity order would the nurse expect to be prescribed?

• A. Bedrest
• B. Encourage ambulation
• C. Out of bed in a chair
• D. No activity restrictions

Correct answer: A

Rationale: Fatigue is a normal response to hepatic cellular damage. During the acute stage, rest is an essential intervention to reduce the metabolic demands on the liver and its blood supply.

5. Your patient with peritonitis is NPO and complaining of thirst. What is your priority?

• A. Increase the I.V. infusion rate.
• B. Use diversion activities.
• C. Provide frequent mouth care.
• D. Give ice chips every 15 minutes.

Correct answer: C

Rationale: The correct answer is C: Provide frequent mouth care. In a patient with peritonitis who is NPO and thirsty, the priority is to maintain oral hygiene and provide comfort by moistening the mouth with frequent mouth care. This helps alleviate the sensation of thirst and maintains oral health. Increasing the IV infusion rate (choice A) may not address the patient's discomfort directly related to thirst. Using diversion activities (choice B) is not as critical as addressing the patient's immediate need for oral care. Giving ice chips every 15 minutes (choice D) is not recommended for a patient with peritonitis who is NPO, as it can lead to complications or worsen the condition.

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