Nursing Elites

1. The following are appropriate nursing interventions during colostomy irrigation, EXCEPT:

• A. Increase the irrigating solution flow rate when abdominal cramps is felt
• B. Insert 2-4 inches of an adequately lubricated catheter to the stoma
• C. Position client in semi-Fowler
• D. Hang the solution 18 inches above the stoma

Correct answer: A

Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.

2. What is the primary purpose of dietary fiber in the diet?

• A. Improving digestion
• B. Providing energy
• C. Aiding in the absorption of vitamins
• D. Reducing cholesterol

Correct answer: D

Rationale: The primary purpose of dietary fiber in the diet is to reduce cholesterol levels. While it does aid in digestion by promoting regular bowel movements, its main role is in lowering cholesterol. Choice A is partially correct but not the primary purpose. Choice B is incorrect as fiber is not a direct source of energy. Choice C is also incorrect as the primary role of fiber is not in the absorption of vitamins.

3. A person who consumes mostly pre-packaged meals is likely consuming too much ____.

• A. iron
• B. zinc
• C. sodium
• D. riboflavin

Correct answer: C

Rationale: Pre-packaged meals often contain high levels of sodium, which can contribute to hypertension and other health issues when consumed in excess.

4. What sensation is used as a gauge so that patients with ileostomy can determine how often their pouch should be drained?

• A. Sensation of taste
• B. Sensation of pressure
• C. Sensation of smell
• D. Urge to defecate

Correct answer: B

Rationale: The correct answer is B: Sensation of pressure. Patients with ileostomy can determine how often their pouch should be drained by feeling the sensation of pressure. This is important as it helps prevent leakage or overflow of the pouch. The sensation of taste (choice A) and smell (choice C) are not typically used as gauges for draining the pouch in ileostomy patients. The urge to defecate (choice D) is not relevant in this context as patients with ileostomy do not pass stool through the rectum.

5. 24 hours after the creation of a colostomy, what should Nurse Violy identify as the normal appearance of the stoma?

• A. Pink, moist, and slightly protruding from the abdomen
• B. Gray, moist, and slightly protruding from the abdomen
• C. Pink, dry, and slightly protruding from the abdomen
• D. Red, moist, and slightly protruding from the abdomen

Correct answer: A

Rationale: Following colostomy surgery, a healthy stoma should appear pink, moist, and slightly protruding from the abdomen, which is why option 'A' is the correct answer. A gray stoma (choice 'B') could indicate poor blood supply or necrosis, which is a serious complication. A dry stoma (choice 'C') is also not normal as it should be moist; a dry stoma may suggest dehydration or other complications. While a stoma can appear red (choice 'D'), this is not typically the normal color; it should usually be pink. Therefore, it's important for healthcare professionals to correctly identify the normal and abnormal appearances of a stoma to ensure proper patient care.

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