Nursing Elites

1. The client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate post-op period for which of the following most frequent complications of this type of surgery?

• A. Intestinal obstruction
• B. Fluid and electrolyte imbalance
• C. Malabsorption of fat
• D. Folate deficiency

Correct answer: B

Rationale: Fluid and electrolyte imbalance is a common complication following ileostomy surgery due to the loss of large volumes of fluid and electrolytes through the stoma. Monitoring and replacing fluids and electrolytes is essential.

2. A nurse is assigned to a 40-year-old client who has a diagnosis of chronic pancreatitis. The nurse reviews the laboratory result, anticipating a laboratory report that indicates a serum amylase level of

• A. 45 units/L
• B. 100 units/L
• C. 300 units/L
• D. 500 units/L

Correct answer: C

Rationale: The normal serum amylase level is 25 to 151 IU/L. With chronic cases of pancreatitis, the rise in serum amylase levels usually does not exceed three times the normal value. In acute pancreatitis, the value may exceed five times the normal value. Options 1 and 2 are within normal limits. Option 3 is an extremely elevated level seen in acute pancreatitis.

3. Which of the following treatments is used for rectal cancer but not for colon cancer?

• A. Chemotherapy
• B. Colonoscopy
• C. Radiation
• D. Surgical resection

Correct answer: C

Rationale: Radiation therapy is commonly used for rectal cancer to shrink the tumor before surgery, which is not typically done for colon cancer.

4. The nurse is caring for a client with a diagnosis of cirrhosis and is monitoring the client for signs of portal hypertension. Which initial sign, if noted in the client, indicates the presence of portal hypertension?

• A. Flat neck veins
• B. Hypotension
• C. Weak pulse
• D. Crackles on auscultation of the lungs

Correct answer: D

Rationale: Clinical signs and symptoms or portal hypertension are identical to those of heart failure and include jugular vein distention, lung crackles, and decreased perfusion to all organs. Initially, the client may have hypertension, flushed skin, and a bounding pulse.

5. After an abdominal resection for colon cancer, Madeline returns to her room with a Jackson-Pratt drain in place. The purpose of the drain is to:

• A. Irrigate the incision with a saline solution.
• B. Prevent bacterial infection of the incision.
• C. Measure the amount of fluid lost after surgery.
• D. Prevent accumulation of drainage in the wound.

Correct answer: D

Rationale: The purpose of the Jackson-Pratt drain is to prevent the accumulation of drainage in the wound after an abdominal resection.

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