Nursing Elites

1. A patient who underwent abdominal surgery now has a gaping incision due to delayed wound healing. Which method is correct when you irrigate a gaping abdominal incision with sterile normal saline solution, using a piston syringe?

• A. Rapidly instill a stream of irrigating solution into the wound.
• B. Apply a wet-to-dry dressing to the wound after the irrigation.
• C. Moisten the area around the wound with normal saline solution after the irrigation.
• D. Irrigate continuously until the solution becomes clear or all of the solution is used.

Correct answer: D

Rationale: Irrigating continuously until the solution becomes clear or all of the solution is used is the correct method when irrigating a gaping abdominal incision.

2. Vasopressin (Pitressin) therapy is prescribed for a client with a diagnosis of bleeding esophageal varices. The nurse is preparing to administer the medication to the client. Which of the following essential items is needed during the administration of this medication?

• A. A cardiac monitor
• B. An intubation set
• C. A suction setup
• D. A tracheotomy set

Correct answer: A

Rationale: The major action of vasopressin is constriction of the splanchnic blood flow. Continuous electrocardiogram and blood pressure monitoring are essential because of the constrictive effects of the medication on the coronary arteries. Options 2, 3, and 4 are not essential items required during the administration of this medication.

3. Which stoma would you expect a malodorous, enzyme-rich, caustic liquid output that is yellow, green, or brown?

• A. Ileostomy.
• B. Ascending colostomy.
• C. Transverse colostomy.
• D. Descending colostomy.

Correct answer: A

Rationale: An ileostomy would have a malodorous, enzyme-rich, caustic liquid output that is yellow, green, or brown.

4. Cholestyramine resin (Questran Light) is prescribed for the client with an elevated serum cholesterol level. The nurse would instruct the client to take the medication

• A. After meals.
• B. Mixed with fruit juice.
• C. Via rectal suppository.
• D. At least 3 hours before meals.

Correct answer: B

Rationale: Cholestyramine resin binds with bile salts in the intestines to form a compound that is excreted in the feces. The client should be instructed to mix the medication with 3 to 6 oz of water, milk, fruit juice, or soup. The medication should be administered before meals. The medication is not administered via rectal suppository.

5. The nurse is performing a colostomy irrigation on a client. During the irrigation, a client begins to complain of abdominal cramps. Which of the following is the most appropriate nursing action?

• A. Notify the physician
• B. Increase the height of the irrigation
• C. Stop the irrigation temporarily.
• D. Medicate with dilaudid and resume the irrigation

Correct answer: C

Rationale: If a client experiences abdominal cramps during a colostomy irrigation, it is appropriate to stop the irrigation temporarily to allow the cramps to subside.

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