Nursing Elites

1. A nurse is caring for a client who has just returned from the operating room following the creation of a colostomy. The nurse is assessing the drainage in the pouch attached to the site where the colostomy was formed and notes serosanguineous drainage. Which nursing action is most appropriate based on this assessment?

• A. Notify the physician
• B. Document the amount and characteristics of the drainage
• C. Apply ice to the stoma site
• D. Apply pressure to the site

Correct answer: B

Rationale: During the first 24 to 72 hours following surgery, mucus and serosanguineous drainage are expected from the stoma. Documenting the amount and characteristics of the drainage is appropriate. The nurse does not need to notify the physician because this is an expected finding. Applying ice or pressure to the site is not necessary.

2. Which of the following areas is the most common site of fistulas in clients with Crohn’s disease?

• A. Anorectal
• B. Ileum
• C. Rectovaginal
• D. Transverse colon

Correct answer: A

Rationale: The anorectal area is the most common site of fistulas in clients with Crohn's disease.

3. The nurse has given instructions to the client with an ileostomy about foods to eat to thicken the stool. The nurse determines that the client needs further instructions if the client stated to eat which of the following foods to make the stools less watery?

• A. Pasta
• B. Boiled rice
• C. Bran
• D. Low-fat cheese

Correct answer: C

Rationale: Bran is high in fiber and should not be consumed to thicken the stool as it will make the stools more watery.

4. Your patient Maria takes NSAIDS for her degenerative joint disease, has developed peptic ulcer disease. Which drug is useful in preventing NSAID-induced peptic ulcer disease?

• A. Calcium carbonate (Tums)
• B. Famotidine (Pepcid)
• C. Misoprostol (Cytotec)
• D. Sucralfate (Carafate)

Correct answer: C

Rationale: Misoprostol (Cytotec) is useful in preventing NSAID-induced peptic ulcer disease.

5. A client with peptic ulcer disease tells the nurse that he has black stools, which he has not reported to his physician. Based on this information, which nursing diagnosis would be appropriate for this client?

• A. Ineffective coping related to fear of diagnosis of chronic illness
• B. Deficient knowledge related to unfamiliarity with significant signs and symptoms
• C. Constipation related to decreased gastric motility
• D. Imbalanced nutrition: Less than body requirements due to gastric bleeding

Correct answer: B

Rationale: Deficient knowledge related to unfamiliarity with significant signs and symptoms is appropriate because the client did not report the black stools, which can be a sign of bleeding.

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