Nursing Elites

1. The nurse aspirates 40 mL of undigested formula from the client’s nasogastric tube. Before administering an intermittent tube feeding, the nurse understands that the 40 mL of gastric aspirate should be

• A. Discarded properly and recorded as output on the client’s intake and output record.
• B. Poured into the nasogastric tube through a syringe with the plunger removed.
• C. Mixed with the formula and poured into the nasogastric tube through a syringe with the plunger removed.
• D. Diluted with water and injected into the nasogastric tube by putting pressure on the plunger.

Correct answer: B

Rationale: After checking the residual feeding contents, the gastric contents are reinstalled into the stomach by removing the syringe bulb or plunger and pouring the gastric contents into the syringe and through the nasogastric tube. Gastric contents should be reinstalled to maintain the client’s electrolyte balance. The gastric contents should be poured into the nasogastric tube through a syringe without a plunger and not injected by putting pressure on the plunger. Gastric contents do not need to be mixed with water or should the contents be discarded.

2. Which area of the alimentary canal is the most common location for Crohn’s disease?

• A. Ascending colon
• B. Descending colon
• C. Sigmoid colon
• D. Terminal ileum

Correct answer: D

Rationale: The terminal ileum is the most common location for Crohn's disease.

3. A client with a peptic ulcer reports epigastric pain that frequently awakens her at night, a feeling of fullness in the abdomen, and a feeling of anxiety about her health. Based on this information, which nursing diagnosis would be most appropriate?

• A. Imbalanced Nutrition: Less than Body Requirements related to anorexia.
• B. Disturbed Sleep Pattern related to epigastric pain
• C. Ineffective Coping related to exacerbation of duodenal ulcer
• D. Activity Intolerance related to abdominal pain

Correct answer: B

Rationale: Disturbed Sleep Pattern related to epigastric pain is appropriate because the client reports pain that frequently awakens her at night.

4. Which of the following nursing interventions should be implemented to manage a client with appendicitis?

• A. Assessing for pain
• B. Encouraging oral intake of clear fluids
• C. Providing discharge teaching
• D. Assessing for symptoms of peritonitis

Correct answer: D

Rationale: The correct answer is D: Assessing for symptoms of peritonitis. This intervention is crucial in managing a client with appendicitis because it indicates a possible rupture of the inflamed appendix. Symptoms of peritonitis include severe abdominal pain, fever, nausea, vomiting, and abdominal rigidity. Prompt recognition of these symptoms is essential for timely intervention and surgical management. Choices A, B, and C are incorrect because while assessing for pain is important, assessing for symptoms of peritonitis takes precedence due to the critical nature of appendicitis. Encouraging oral intake of clear fluids and providing discharge teaching are not immediate priorities in the management of a client with acute appendicitis.

5. You’re preparing a patient with a malignant tumor for colorectal surgery and subsequent colostomy. The patient tells you he’s anxious. What should your initial step be in working with this patient?

• A. Determine what the patient already knows about colostomies.
• B. Show the patient some pictures of colostomies.
• C. Arrange for someone who has a colostomy to visit the patient.
• D. Provide the patient with written material about colostomy care.

Correct answer: A

Rationale: When a patient with a malignant tumor is anxious about colorectal surgery and a colostomy, the initial step is to determine what the patient already knows about colostomies.

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