Nursing Elites

1. A nurse is caring for a client diagnose with pancreatitis. The nurse anticipates that the client would not experience an elevation of which of the following enzymes?

• A. Lipase
• B. Lactase
• C. Amylase
• D. Trypsin

Correct answer: B

Rationale: Lactase is produced in the small intestine and aids in splitting neutral fats into glycerol and fatty acids. Lipase, amylase, and trypsin are produced in the pancreas and aid in the digestion of fats, starches, and proteins, respectively.

2. After gastric resection surgery, which of the following signs and symptoms would alert the nurse to the development of a leaking anastomosis?

• A. Pain, fever, and abdominal rigidity.
• B. Diarrhea with fat in the stool.
• C. Palpitations, pallor, and diaphoresis after eating.
• D. Feelings of fullness and nausea after eating.

Correct answer: A

Rationale: Pain, fever, and abdominal rigidity are signs and symptoms of inflammation or peritonitis caused by the leaking anastomosis. Diarrhea with fat in the stool is steatorrhea and is not present in peritonitis. Palpitations, pallor, and diaphoresis after eating are vasomotor symptoms of gastric retention. Feelings of fullness and nausea after eating are not present in peritonitis.

3. A client had an abdominal perineal resection with a colostomy 4 days ago and is ready for discharge. Which of the following would be an appropriate expected outcome at this point?

• A. The client maintains a high-fiber diet.
• B. The client discusses concerns about his sexual functioning.
• C. The client maintains bedrest.
• D. The client limits fluid intake to 1000 ml/day.

Correct answer: B

Rationale: Clients often have concerns about their sexuality after a fecal diversion. The nurse should encourage the client to discuss any questions about sexual functioning. The client will not need to maintain a high-fiber diet but will be encouraged to avoid any foods that cause odor and flatulence. The client should be able to ambulate and sit out of bed for several hours at a time at this point. Fluid intake will be encouraged, not restricted.

4. The nurse is assessing for stoma prolapse in a client with a colostomy. The nurse would observe which of the following if stoma prolapse occurred?

• A. Sunken and hidden stoma
• B. Dark- and bluish-colored stoma
• C. Narrowed and flattened stoma
• D. Protruding stoma

Correct answer: D

Rationale: A protruding stoma is indicative of stoma prolapse, which occurs when the bowel protrudes excessively through the stoma.

5. An enema is prescribed for a client with suspected appendicitis. Which of the following actions should the nurse take?

• A. Prepare 750 ml of irrigating solution warmed to 100*F
• B. Question the physician about the order
• C. Provide privacy and explain the procedure to the client
• D. Assist the client to left lateral Sim’s position

Correct answer: B

Rationale: An enema is contraindicated in clients with suspected appendicitis because it can increase the risk of perforation. It is important to verify the appropriateness of this order with the physician.

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