Nursing Elites

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

• A. Diarrhea related to alteration in bowel elimination.
• B. Impaired skin integrity related to seepage.
• C. Impaired nutrition: More than body requirements related to high-fat diet.
• D. Impaired physical mobility related to surgical procedure.

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.

2. Your patient has a retractable gastric peptic ulcer and has had a gastric vagotomy. Which factor increases as a result of vagotomy?

• A. Peristalsis.
• B. Gastric acidity.
• C. Gastric motility.
• D. Gastric pH.

Correct answer: D

Rationale: After a gastric vagotomy, the gastric pH increases as a result of reduced acid secretion.

3. Five days after undergoing surgery, a client develops a small-bowel obstruction. A Miller-Abbott tube is inserted for bowel decompression. Which nursing diagnosis takes priority?

• A. Imbalanced nutrition: Less than body requirements
• B. Acute pain
• C. Deficient fluid volume
• D. Excess fluid volume

Correct answer: C

Rationale: For a client with a small-bowel obstruction and a Miller-Abbott tube, deficient fluid volume is the priority nursing diagnosis.

4. During an abdominal assessment, a nurse finds pulsation between the umbilicus and pubis on a client. What finding should be reported to the physician?

• A. Concave, midline umbilicus
• B. Pulsation between the umbilicus and pubis
• C. Bowel sound frequency of 15 sounds per minute
• D. Absence of a bruit

Correct answer: B

Rationale: The presence of pulsation between the umbilicus and pubis could indicate an abdominal aortic aneurysm, which is a serious condition and should be reported to the physician promptly. A concave, midline umbilicus is a normal finding. Bowel sound frequency can vary widely and is not a cause for concern at 15 sounds per minute. Absence of a bruit is a normal finding in an abdominal assessment and does not require reporting.

5. The nurse is caring for a client on the first postoperative day following a surgical repair of an abdominal aortic aneurysm. Which nursing diagnosis is the most important for this client?

• A. Risk for infection
• B. Deficient knowledge
• C. Ineffective peripheral tissue perfusion
• D. Activity intolerance

Correct answer: C

Rationale: Peripheral tissue perfusion is a major concern in the postoperative period following an abdominal aneurysm repair. Peripheral pulses should be checked frequently during the first 24 hours. A weak or absent pulse may be a sign of embolization or graft closure, especially if accompanied by a pale, cold, mottled extremity; the nurse should immediately report this to the surgeon. Risk for infection, deficient knowledge, and activity intolerance are all important nursing diagnoses in the postoperative period, but peripheral tissue perfusion is the most immediate concern.

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