Nursing Elites

1. After abdominal surgery, your patient has a severe coughing episode that causes wound evisceration. In addition to calling the doctor, which intervention is most appropriate?

• A. Irrigate the wound & organs with Betadine.
• B. Cover the wound with a saline soaked sterile dressing.
• C. Apply a dry sterile dressing & binder.
• D. Push the organs back & cover with moist sterile dressings.

Correct answer: B

Rationale: Covering the wound with a saline soaked sterile dressing is the most appropriate intervention for wound evisceration.

2. A client had an abdominal perineal resection with a colostomy 4 days ago and is ready for discharge. Which of the following would be an appropriate expected outcome at this point?

• A. The client maintains a high-fiber diet.
• B. The client discusses concerns about his sexual functioning.
• C. The client maintains bedrest.
• D. The client limits fluid intake to 1000 ml/day.

Correct answer: B

Rationale: Clients often have concerns about their sexuality after a fecal diversion. The nurse should encourage the client to discuss any questions about sexual functioning. The client will not need to maintain a high-fiber diet but will be encouraged to avoid any foods that cause odor and flatulence. The client should be able to ambulate and sit out of bed for several hours at a time at this point. Fluid intake will be encouraged, not restricted.

3. A client with a peptic ulcer reports epigastric pain that frequently awakens her at night, a feeling of fullness in the abdomen, and a feeling of anxiety about her health. Based on this information, which nursing diagnosis would be most appropriate?

• A. Imbalanced Nutrition: Less than Body Requirements related to anorexia.
• B. Disturbed Sleep Pattern related to epigastric pain
• C. Ineffective Coping related to exacerbation of duodenal ulcer
• D. Activity Intolerance related to abdominal pain

Correct answer: B

Rationale: Disturbed Sleep Pattern related to epigastric pain is appropriate because the client reports pain that frequently awakens her at night.

4. The nurse aspirates 40 mL of undigested formula from the client’s nasogastric tube. Before administering an intermittent tube feeding, the nurse understands that the 40 mL of gastric aspirate should be

• A. Discarded properly and recorded as output on the client’s intake and output record.
• B. Poured into the nasogastric tube through a syringe with the plunger removed.
• C. Mixed with the formula and poured into the nasogastric tube through a syringe with the plunger removed.
• D. Diluted with water and injected into the nasogastric tube by putting pressure on the plunger.

Correct answer: B

Rationale: After checking the residual feeding contents, the gastric contents are reinstalled into the stomach by removing the syringe bulb or plunger and pouring the gastric contents into the syringe and through the nasogastric tube. Gastric contents should be reinstalled to maintain the client’s electrolyte balance. The gastric contents should be poured into the nasogastric tube through a syringe without a plunger and not injected by putting pressure on the plunger. Gastric contents do not need to be mixed with water or should the contents be discarded.

5. Anna is 45 y.o. and has a bleeding ulcer. Despite multiple blood transfusions, her HGB is 7.5g/dl and HCT is 27%. Her doctor determines that surgical intervention is necessary and she undergoes partial gastrectomy. Postoperative nursing care includes:

• A. Giving pain medication Q6H.
• B. Flushing the NG tube with sterile water.
• C. Positioning her in high Fowler’s position.
• D. Keeping her NPO until the return of peristalsis.

Correct answer: D

Rationale: Postoperative care for a patient who underwent partial gastrectomy includes keeping her NPO until the return of peristalsis to prevent complications.

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