Nursing Elites

1. After a subtotal gastrectomy, care of the client’s nasogastric tube and drainage system should include which of the following nursing interventions?

• A. Irrigate the tube with 30 ml of sterile water every hour, if needed.
• B. Reposition the tube if it is not draining well
• C. Monitor the client for N/V, and abdominal distention
• D. Turn the machine to high suction of the drainage is sluggish on low suction.

Correct answer: C

Rationale: Monitoring the client for nausea, vomiting, and abdominal distention is crucial for ensuring proper functioning of the nasogastric tube and drainage system.

2. In a client with Crohn’s disease, which of the following symptoms should not be a direct result from antibiotic therapy?

• A. Decrease in bleeding
• B. Decrease in temperature
• C. Decrease in body weight
• D. Decrease in the number of stools

Correct answer: C

Rationale: Decrease in body weight is not a direct result of antibiotic therapy but may occur due to the underlying disease process.

3. You have to teach ostomy self care to a patient with a colostomy. You tell the patient to measure and cut the wafer:

• A. To the exact size of the stoma.
• B. About 1/16” larger than the stoma.
• C. About 1/8” larger than the stoma.
• D. About 1/4″ larger than the stoma.

Correct answer: C

Rationale: The wafer should be measured and cut about 1/8” larger than the stoma to ensure proper fit and prevent skin irritation.

4. A nurse is caring for a client who has a new diagnosis of Crohn's disease. Which of the following findings should the nurse expect?

• A. Bloody diarrhea
• B. Fatty stools
• C. Weight gain
• D. High fever

Correct answer: B

Rationale: Clients with Crohn's disease often experience fatty stools (steatorrhea) due to malabsorption of fats. This occurs because the inflammation caused by Crohn's disease can affect the small intestine, impairing the body's ability to absorb nutrients. Bloody diarrhea is more commonly associated with ulcerative colitis. Weight gain is not a typical symptom of Crohn's disease; instead, weight loss is more common due to malabsorption and decreased appetite. High fever can occur during acute flare-ups but is not a primary finding of Crohn's disease.

5. The nurse assesses the client's understanding of the relationship between body position and gastroesophageal reflux. Which response would indicate that the client understands measures to avoid problems with reflux while sleeping?

• A. I can elevate the foot of the bed 4 to 6 inches.
• B. I can sleep on my stomach with my head turned to the left.
• C. I can sleep on my back without a pillow under my head.
• D. I can elevate the head of the bed 4 to 6 inches.

Correct answer: D

Rationale: Sleeping with the head of the bed elevated encourages movement of food through the esophagus by gravity. By fostering esophageal acid clearance, gravity helps keep the acidic pepsin and alkaline biliary secretions from contacting the esophagus. Elevating the foot of the bed does not affect clearance of esophageal acid. Sleeping on the stomach with the head turned to the left will not decrease reflux incidence. Sleeping flat without a pillow under the head does not enhance clearance.

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