Nursing Elites

1. The client with a colostomy has an order for irrigation of the colostomy. The nurse used which solution for irrigation?

• A. Distilled water
• B. Tap water
• C. Sterile water
• D. Lactated Ringer’s

Correct answer: B

Rationale: Tap water at body temperature is generally used for colostomy irrigation unless the local water supply is not safe for drinking, in which case bottled water can be used.

2. Arthur has a family history of colon cancer and is scheduled to have a sigmoidoscopy. He is crying as he tells you, “I know that I have colon cancer, too.” Which response is most therapeutic?

• A. I know just how you feel.
• B. You seem upset.
• C. Oh, don’t worry about it, everything will be just fine.
• D. Why do you think you have cancer?

Correct answer: B

Rationale: Acknowledging the patient's emotions with 'You seem upset' is the most therapeutic response.

3. The client who has undergone creation of a colostomy has a nursing diagnosis of Disturbed body image. The nurse would evaluate that the client is making the most significant progress toward identified goals if the client:

• A. Watches the nurse empty the colostomy bag
• B. Looks at the ostomy site
• C. Reads the ostomy product literature
• D. Practices cutting the ostomy appliance

Correct answer: D

Rationale: The correct answer is D: Practices cutting the ostomy appliance. This choice indicates that the client is actively involved in self-care and adapting to the colostomy. By practicing cutting the ostomy appliance, the client is demonstrating independence and self-management skills, showing significant progress towards overcoming the disturbed body image. Choices A, B, and C do not involve active participation in self-care tasks related to the colostomy, which are essential for the client's adaptation and acceptance.

4. While caring for a client with peptic ulcer disease, the client reports that he has been nauseated most of the day and is now feeling lightheaded and dizzy. Based upon these findings, which nursing actions would be most appropriate for the nurse to take?

• A. Administering an antacid hourly until nausea subsides.
• B. Monitoring the client's vital signs
• C. Notifying the family and friends of the client's symptoms
• D. Initiating oxygen therapy

Correct answer: B

Rationale: Monitoring the client's vital signs and notifying the physician of the client's symptoms are crucial actions based on the reported symptoms.

5. You have to teach ostomy self care to a patient with a colostomy. You tell the patient to measure and cut the wafer:

• A. To the exact size of the stoma.
• B. About 1/16” larger than the stoma.
• C. About 1/8” larger than the stoma.
• D. About 1/4″ larger than the stoma.

Correct answer: C

Rationale: The wafer should be measured and cut about 1/8” larger than the stoma to ensure proper fit and prevent skin irritation.

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