Nursing Elites

1. A client with rectal cancer may exhibit which of the following symptoms?

• A. Abdominal fullness
• B. Gastric fullness
• C. Rectal bleeding
• D. Right upper quadrant pain

Correct answer: C

Rationale: Rectal bleeding is a common symptom in clients with rectal cancer.

2. If a gastric acid perforates, which of the following actions should not be included in the immediate management of the client?

• A. Blood replacement
• B. Antacid administration
• C. Nasogastric tube suction
• D. Fluid and electrolyte replacement

Correct answer: B

Rationale: Antacid administration should not be included in the immediate management of a gastric perforation.

3. The nurse is irrigating a client's colostomy when she complains of abdominal cramping after receiving about 100 mL of the irrigating solution. What should the nurse's first response be in this situation?

• A. Stop the flow of solution temporarily.
• B. Reposition the client on to her right side.
• C. Remove the irrigation tube.
• D. Massage the abdomen gently.

Correct answer: A

Rationale: The abdominal cramping that can occur during colostomy irrigation results from stimulation of the colon by the irrigating solution. The nurse's first response should be to temporarily stop the flow of solution to allow the cramping to subside. Repositioning the client to the right side will not alleviate the cramping. Removing the tube will not decrease the cramping and will necessitate reinsertion of the tube when the irrigation is resumed. Massaging the abdomen gently may be soothing to some clients, but it is not the nurse's first priority action.

4. Rob is a 46 y.o. admitted to the hospital with a suspected diagnosis of Hepatitis B. He’s jaundiced and reports weakness. Which intervention will you include in his care?

• A. Regular exercise.
• B. A low-protein diet.
• C. Allow patient to select his meals.
• D. Rest period after small, frequent meals.

Correct answer: D

Rationale: For a patient with hepatitis B who is jaundiced and reports weakness, providing rest periods after small, frequent meals is important.

5. You’re doing preoperative teaching with Gertrude who has ulcerative colitis who needs surgery to create an ileoanal reservoir. Which information do you include?

• A. A reservoir is created that exits through the abdominal wall.
• B. A second surgery is required 12 months after the first surgery.
• C. A permanent ileostomy is created.
• D. The surgery occurs in two stages.

Correct answer: D

Rationale: The surgery to create an ileoanal reservoir occurs in two stages.

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