Nursing Elites

1. A client with viral hepatitis states, 'I am so yellow.' The nurse most appropriately would

• A. Assist the client in expressing feelings.
• B. Do most of the activities of daily living for the client.
• C. Provide information to the client only when the client requests it.
• D. Restrict visitors until the jaundice subsides.

Correct answer: A

Rationale: To assist the client in adapting to changes in appearance, the nurse must encourage participation in self-care to foster independence and self-esteem. The nurse should encourage the client to ask questions to clarify misconceptions, learn ways to prevent the spread of hepatitis to reduce fear, and make appropriate decisions. Restricting visitors will reinforce the client’s negative self-esteem.

2. A client is providing instructions to a client who is scheduled for an oral cholecystogram. The nurse tells the client to

• A. Eat a fat-free meal on the evening before the procedure.
• B. Maintain strict NPO status on the day of the procedure.
• C. Avoid oral intake except for water on the day of the procedure.
• D. Eat a high-fat meal for breakfast on the day of the procedure.

Correct answer: C

Rationale: For an oral cholecystogram, the client should eat a fat-free meal the evening before the procedure and avoid oral intake except for water on the day of the procedure. During the test, the client may be given a high-fat meal or drink to stimulate gallbladder emptying. Choice A is incorrect because the client should have a fat-free meal, not a high-fat meal. Choice B is incorrect as strict NPO status is not required. Choice D is incorrect as a high-fat meal is not recommended for breakfast on the day of the procedure.

3. The nurse is doing preoperative teaching with the client who is about to undergo creation of a Kock pouch. The nurse interprets that the client has the best understanding of the nature of the surgery if the client makes which of the following statements?

• A. I will need to drain the pouch regularly with a catheter.
• B. I will need to wear a drainage bag for the rest of my life.
• C. The drainage from this type of ostomy will be formed.
• D. I will be able to pass stool from the rectum eventually.

Correct answer: A

Rationale: A Kock pouch is a continent ileostomy. As the ileostomy begins to function, the client drains it every 3 to 4 hours and then decreases the draining about 3 times a day or as needed when full. The client does not need to wear a drainage bag but should wear an absorbent dressing to absorb mucous drainage from the stoma. Ileostomy drainage is liquid. The client would be able to pass stool only from the rectum if an ileal-anal pouch or anastomosis were created. This type of operation is a two-stage procedure.

4. The physician orders a Salem sump tube for gastrointestinal intubation. The nurse prepares for the insertion and obtains which of the following items from the supply room?

• A. A tube with a single lumen that connects to suction
• B. A tube with a large lumen and an air vent
• C. A Sengstaken-Blakemore tube
• D. A Dobbhoff weighted tube

Correct answer: B

Rationale: A tube with a large lumen and an air vent is a Salem sump tube. A tube with a single lumen is called a Levin’s tube. A Sengstaken-Blakemore tube is used to control bleeding in the esophagus. A Dobbhoff weighted tube is used for feedings.

5. A client with peptic ulcer is scheduled for a Vagotomy. The client asks the nurse about the purpose of this procedure. The nurse tells the client that the procedure

• A. Decreases food absorption in the stomach.
• B. Heals the gastric mucosa.
• C. Halts stress reactions.
• D. Reduces the stimulus to acid secretions.

Correct answer: D

Rationale: A vagotomy, or cutting of the vagus nerve, is done to eliminate parasympathetic stimulation of gastric secretion, thereby reducing the stimulus to acid secretions. Options A, B, and C are incorrect as a vagotomy does not affect food absorption, heal the gastric mucosa, or halt stress reactions.

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