Nursing Elites

1. A nurse is preparing to remove a nasogastric tube from a client. The nurse would instruct the client to do which of the following just before the nurse removes the tube?

• A. To perform Valsalva’s maneuver
• B. To take hold and hold a deep breath
• C. To exhale
• D. To inhale and exhale quickly

Correct answer: B

Rationale: When the nurse removes a nasogastric tube, the client is instructed to take and hold a deep breath. This will be obstructed temporarily during the tube removal. This allows for easy withdrawal through the esophagus into the nose. The nurse removes the tube with one smooth, continuous pull.

2. Annebell is being discharged with a colostomy, and you’re teaching her about colostomy care. Which statement correctly describes a healthy stoma?

• A. At first, the stoma may bleed slightly when touched.
• B. The stoma should appear dark and have a bluish hue.
• C. A burning sensation under the stoma faceplate is normal.
• D. The stoma should remain swollen away from the abdomen.

Correct answer: A

Rationale: A healthy stoma may bleed slightly when touched initially, which is normal.

3. The nurse is scheduling diagnostic tests for a client. If all of the following diagnostic tests are ordered, which would be performed last?

• A. Gallbladder series
• B. Barium enema
• C. Barium swallow
• D. Oral cholecystogram

Correct answer: C

Rationale: The correct answer is C, 'Barium swallow.' A barium swallow should be done after a barium enema or gallbladder series to prevent the contrast used in the barium swallow from obstructing the view of other organs. It takes several days for swallowed barium to pass completely out of the gastrointestinal tract. Choices A, B, and D are incorrect because a barium swallow should be the last test performed to ensure clear imaging without interference from residual contrast material.

4. Which of the following factors is believed to be linked to Crohn’s disease?

• A. Constipation
• B. Diet
• C. Hereditary
• D. Lack of exercise

Correct answer: C

Rationale: Crohn's disease is believed to have a hereditary link, with genetic factors playing a significant role in its development.

5. The nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client to:

• A. restrict fluid intake to 1 qt (1,000 ml)/day.
• B. drink liquids only with meals.
• C. don't drink liquids 2 hours before meals.
• D. drink liquids only between meals.

Correct answer: D

Rationale: A client who experiences dumping syndrome after a subtotal gastrectomy should be advised to ingest liquids between meals rather than with meals. Taking fluids between meals allows for adequate hydration, reduces the amount of bulk ingested with meals, and aids in preventing rapid gastric emptying. There is no need to restrict the amount of fluids, just the time when the client drinks fluids. Drinking liquids with meals increases the risk of dumping syndrome by increasing the amount of bulk and stimulating rapid gastric emptying. Small amounts of water are allowable before meals.

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