Nursing Elites

1. The nurse is doing preoperative 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 the rectum eventually.

Correct answer: A

Rationale: A Kock pouch is a continent ileostomy. As the ileostomy begins to function, the client drains it every 3 to 4 hours and then decreases the draining about 3 times a day or as needed when full. The client does not need to wear a drainage bag but should wear an absorbent dressing to absorb mucous drainage from the stoma. Ileostomy drainage is liquid. The client would be able to pass stool only from the rectum if an ileal-anal pouch or anastomosis were created. This type of operation is a two-stage procedure.

2. Cholestyramine resin (Questran Light) is prescribed for the client with an elevated serum cholesterol level. The nurse would instruct the client to take the medication

• A. After meals.
• B. Mixed with fruit juice.
• C. Via rectal suppository.
• D. At least 3 hours before meals.

Correct answer: B

Rationale: Cholestyramine resin binds with bile salts in the intestines to form a compound that is excreted in the feces. The client should be instructed to mix the medication with 3 to 6 oz of water, milk, fruit juice, or soup. The medication should be administered before meals. The medication is not administered via rectal suppository.

3. 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.

4. 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.

5. A patient has an acute upper GI hemorrhage. Your interventions include:

• A. Treating hypovolemia.
• B. Treating hypervolemia.
• C. Controlling the bleeding source.
• D. Treating shock and diagnosing the bleeding source.

Correct answer: D

Rationale: For a patient with an acute upper GI hemorrhage, your interventions include treating shock and diagnosing the bleeding source.

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