Nursing Elites

1. Sitty, a 66 y.o. patient underwent a colostomy for ruptured diverticulum. She did well during the surgery and returned to your med-surg floor in stable condition. You assess her colostomy 2 days after surgery. Which finding do you report to the doctor?

• A. Blanched stoma
• B. Edematous stoma
• C. Reddish-pink stoma
• D. Brownish-black stoma

Correct answer: A

Rationale: A blanched stoma 2 days after colostomy surgery should be reported to the doctor as it may indicate compromised blood flow.

2. The client is admitted to the hospital with viral hepatitis, complaining of 'no appetite' and 'losing my taste for food.' To provide adequate nutrition, the nurse would instruct the client to

• A. Eat a good supper when anorexia is not as severe.
• B. Eat less often, preferably only three large meals daily.
• C. Increase intake of fluids including juices.
• D. Select foods high in fat.

Correct answer: C

Rationale: Although no special diet is required to treat viral hepatitis, it is generally recommended that clients consume a diet with low-fat content because fat may be tolerated poorly due to decreased bile production. Small, frequent meals are preferable and may prevent nausea. Appetite is often better in the morning, so it is easier to eat a good breakfast. An adequate fluid intake of 2500 to 3000 mL per day that includes nutritional juices is also important.

3. The client with Crohn’s disease has a nursing diagnosis of Acute Pain. The nurse would teach the client to avoid which of the following in managing this problem?

• A. Lying supine with the legs straight
• B. Massaging the abdomen
• C. Using antispasmodic medication
• D. Using relaxation techniques

Correct answer: A

Rationale: In managing acute pain associated with Crohn’s disease, the client should avoid lying supine with the legs straight. This position increases muscle tension in the abdomen, potentially aggravating inflamed intestinal tissues as the abdominal muscles are stretched. Massaging the abdomen, using antispasmodic medication, and employing relaxation techniques are beneficial in alleviating pain. Massaging can help relax abdominal muscles, antispasmodic medication can reduce spasms contributing to pain, and relaxation techniques aid in overall pain management. Therefore, choices B, C, and D are appropriate interventions for managing pain in clients with CroCrohn’s disease.

4. A nurse is developing a teaching plan for the client with viral hepatitis. The nurse plans to tell the client which of the following in the teaching session?

• A. Activity should be limited to prevent fatigue
• B. The diet should be low in calories
• C. Meals should be large to conserve energy
• D. Alcohol intake should be limited to 2 oz. per day.

Correct answer: A

Rationale: The client with viral hepatitis should limit activity to avoid fatigue during the recuperation period. The diet should be optimal in calories, proteins, and carbohydrates. The client should take in several small meals per day. Alcohol is strictly forbidden.

5. You’re preparing a teaching plan for a 27 y.o. named Jeff who underwent surgery to close a temporary ileostomy. Which nutritional guideline do you include in this plan?

• A. There is no need to change eating habits.
• B. Eat six small meals a day.
• C. Eat the largest meal in the evening.
• D. Restrict fluid intake.

Correct answer: B

Rationale: After ileostomy closure surgery, it is recommended to eat six small meals a day to aid digestion and absorption.

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