Nursing Elites

1. The nurse is doing pre-op teaching with the client who is about to undergo creation of a Kock pouch. The nurse interprets that the client has the best understanding of the nature of the surgery if the client makes which of the following statements?

• A. I will need to drain the pouch regularly with a catheter.
• B. I will need to wear a drainage bag for the rest of my life.
• C. The drainage from this type of ostomy will be formed.
• D. I will be able to pass stool from my rectum eventually.

Correct answer: A

Rationale: A Kock pouch is a type of continent ileostomy that requires catheterization to empty the internal reservoir. Understanding the need for regular catheterization indicates the client comprehends the procedure.

2. Five days after undergoing surgery, a client develops a small-bowel obstruction. A Miller-Abbott tube is inserted for bowel decompression. Which nursing diagnosis takes priority?

• A. Imbalanced nutrition: Less than body requirements
• B. Acute pain
• C. Deficient fluid volume
• D. Excess fluid volume

Correct answer: C

Rationale: For a client with a small-bowel obstruction and a Miller-Abbott tube, deficient fluid volume is the priority nursing diagnosis.

3. After a subtotal gastrectomy, the nurse should anticipate that nasogastric tube drainage will be what color for about 12 to 24 hours after surgery?

• A. Dark brown
• B. Bile green
• C. Bright red
• D. Cloudy white

Correct answer: A

Rationale: Dark brown drainage is expected for about 12 to 24 hours after surgery.

4. Which of the following aspects is the priority focus of nursing management for a client with peritonitis?

• A. Fluid and electrolyte balance
• B. Gastric irrigation
• C. Pain management
• D. Psychosocial issues

Correct answer: A

Rationale: The priority focus of nursing management for a client with peritonitis is fluid and electrolyte balance to prevent shock.

5. 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.

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