Nursing Elites

1. An intubated patient is receiving continuous enteral feedings through a Salem sump tube at a rate of 60ml/hr. Gastric residuals have been 30-40ml when monitored Q4H. You check the gastric residual and aspirate 220ml. What is your first response to this finding?

• A. Notify the doctor immediately.
• B. Stop the feeding, and clamp the NG tube.
• C. Discard the 220ml, and clamp the NG tube.
• D. Give a prescribed GI stimulant such as metoclopramide (Reglan).

Correct answer: B

Rationale: If gastric residuals are high during continuous enteral feedings, the first response is to stop the feeding and clamp the NG tube.

2. The nurse is assessing for stoma prolapse in a client with a colostomy. The nurse would observe which of the following if stoma prolapse occurred?

• A. Sunken and hidden stoma
• B. Dark- and bluish-colored stoma
• C. Narrowed and flattened stoma
• D. Protruding stoma

Correct answer: D

Rationale: A protruding stoma is indicative of stoma prolapse, which occurs when the bowel protrudes excessively through the stoma.

3. A client is recovering from an ileostomy that was performed to treat inflammatory bowel disease. During discharge teaching for this client, the nurse should stress:

• A. increasing fluid intake to prevent dehydration.
• B. wearing an appliance pouch at all times.
• C. consuming a low-protein, high-fiber diet.
• D. avoiding enteric-coated medications.

Correct answer: A

Rationale: The correct answer is A: increasing fluid intake to prevent dehydration. An ileostomy typically drains liquid waste, so the client is at risk of fluid loss. By increasing fluid intake, the client can prevent dehydration. It's essential for the client to wear a collection appliance at all times because ileostomy drainage is incontinent. Consuming a low-protein, high-fiber diet is not recommended as high-fiber foods can cause intestinal irritation. Enteric-coated medications should be avoided because they may not be absorbed properly after an ileostomy.

4. 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.

5. A client with viral hepatitis states, 'I am so yellow.' The nurse most appropriately would

• A. Assist the client in expressing feelings.
• B. Do most of the activities of daily living for the client.
• C. Provide information to the client only when the client requests it.
• D. Restrict visitors until the jaundice subsides.

Correct answer: A

Rationale: To assist the client in adapting to changes in appearance, the nurse must encourage participation in self-care to foster independence and self-esteem. The nurse should encourage the client to ask questions to clarify misconceptions, learn ways to prevent the spread of hepatitis to reduce fear, and make appropriate decisions. Restricting visitors will reinforce the client’s negative self-esteem.

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