Nursing Elites

1. A nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis. The client is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment the nurse notes that the abdomen is distended and the bowel sounds are diminished. Which of the following is the most appropriate nursing intervention?

• A. Administer dilaudid
• B. Notify the physician
• C. Call and ask the operating room team to perform the surgery as soon as possible
• D. Reposition the client and apply a heating pad on a warm setting to the client’s abdomen.

Correct answer: B

Rationale: The symptoms suggest possible perforation or peritonitis, which are serious complications requiring immediate medical attention. The nurse should promptly notify the physician.

2. A client has a nasogastric tube inserted at the time of abdominal perineal resection with permanent colostomy. This tube will most likely be removed when the client demonstrates:

• A. Absence of nausea and vomiting.
• B. Passage of mucus from the rectum.
• C. Passage of flatus and feces from the colostomy.
• D. Absence of stomach drainage for 24 hours.

Correct answer: C

Rationale: A sign indicating that a client's colostomy is open and ready to function is passage of feces and flatus. When this occurs, gastric suction is ordinarily discontinued, and the client is allowed to start taking fluids and food orally. Absence of bowel sounds would indicate that the tube should remain in place because peristalsis has not yet returned. Absence of nausea and vomiting is not a criterion for judging whether or not gastric suction should be continued. Passage of mucus from the rectum will not occur in this client because the rectum is removed in this surgery. Absence of stomach drainage is not a criterion for judging whether or not gastric suction should be continued.

3. Before bowel surgery, Lee is to administer enemas until clear. During administration, he complains of intestinal cramps. What do you do next?

• A. Discontinue the procedure.
• B. Lower the height of the enema container.
• C. Complete the procedure as quickly as possible.
• D. Continue administration of the enema as ordered without making any adjustments.

Correct answer: B

Rationale: If a patient complains of intestinal cramps during an enema, lowering the height of the enema container can help reduce discomfort.

4. When assessing the client with celiac disease, the nurse can expect to find which of the following?

• A. Steatorrhea
• B. Jaundiced sclerae
• C. Clay-colored stools
• D. Widened pulse pressure

Correct answer: A

Rationale: Because celiac disease destroys the absorbing surface of the intestine, fat isn't absorbed but is passed in the stool. Steatorrhea is bulky, fatty stools that have a foul odor. Jaundiced sclerae result from elevated bilirubin levels. Clay-colored stools are seen with biliary disease when bile flow is blocked. Celiac disease doesn't cause a widened pulse pressure.

5. Sitty, a 66 y.o. patient underwent a colostomy for ruptured diverticulum. She did well during the surgery and returned to your med-surg floor in stable condition. You assess her colostomy 2 days after surgery. Which finding do you report to the doctor?

• A. Blanched stoma
• B. Edematous stoma
• C. Reddish-pink stoma
• D. Brownish-black stoma

Correct answer: A

Rationale: A blanched stoma 2 days after colostomy surgery should be reported to the doctor as it may indicate compromised blood flow.

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