Nursing Elites

1. During the first few days of recovery from ostomy surgery for ulcerative colitis, which of the following aspects should be the first priority of client care?

• A. Body image
• B. Ostomy care
• C. Sexual concerns
• D. Skin care

Correct answer: D

Rationale: During the initial recovery period from ostomy surgery, skin care is the first priority to prevent irritation and infection around the stoma site.

2. The nurse instructs the ileostomy client to do which of the following as a part of essential care of the stoma?

• A. Cleanse the peristomal skin meticulously
• B. Take in high-fiber foods such as nuts
• C. Massage the area below the stoma
• D. Limit fluid intake to prevent diarrhea.

Correct answer: A

Rationale: Cleansing the peristomal skin meticulously is crucial to prevent irritation and infection around the stoma.

3. You’re performing an abdominal assessment on Brent who is 52 y.o. In which order do you proceed?

• A. Observation, percussion, palpation, auscultation
• B. Observation, auscultation, percussion, palpation
• C. Percussion, palpation, auscultation, observation
• D. Palpation, percussion, observation, auscultation

Correct answer: B

Rationale: The correct order for performing an abdominal assessment is observation, auscultation, percussion, and palpation.

4. A nurse is inserting a nasogastric tube in an adult client. During the procedure, the client begins to cough and has difficulty breathing. Which of the following is the most appropriate nursing action?

• A. Remove the tube and reinsert when the respiratory distress subsides.
• B. Pull back on the tube and wait until the respiratory distress subsides.
• C. Quickly insert the tube.
• D. Notify the physician immediately.

Correct answer: B

Rationale: During the insertion of a nasogastric tube, if the client experiences difficulty breathing or any respiratory distress, withdraw the tube slightly, stop the tube advancement, and wait until the distress subsides. Options 1 and 4 are unnecessary. Quickly inserting the tube is not an appropriate action because, in this situation, it may be likely that the tube has entered the bronchus.

5. When a client has peptic ulcer disease, the nurse would expect a priority intervention to be:

• A. Assisting in inserting a Miller-Abbott tube
• B. Assisting in inserting an arterial pressure line
• C. Inserting a nasogastric tube
• D. Inserting an I.V.

Correct answer: C

Rationale: Inserting a nasogastric tube is a priority intervention for a client with peptic ulcer disease to decompress the stomach.

Similar Questions