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

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

Correct answer: B

Rationale: The correct solution to use for the irrigation of a colostomy is warm tap water or saline solution. If tap water is not suitable for drinking, bottled water can be used. Distilled water, sterile water, and Lactated Ringer’s are not appropriate solutions for colostomy irrigation. Distilled water lacks essential minerals, sterile water may not provide adequate cleaning, and Lactated Ringer’s is not indicated for this procedure.

3. Develop a teaching care plan for Angie who is about to undergo a liver biopsy. Which of the following points do you include?

• A. You’ll need to lie on your stomach during the test.
• B. You’ll need to lie on your right side after the test.
• C. During the biopsy you’ll be asked to exhale deeply and hold it.
• D. The biopsy is performed under general anesthesia.

Correct answer: B

Rationale: Instruct the patient to lie on their right side after the biopsy to apply pressure and prevent bleeding.

4. You’re advising a 21 y.o. with a colostomy who reports problems with flatus. What food should you recommend?

• A. Peas
• B. Cabbage
• C. Broccoli
• D. Yogurt

Correct answer: D

Rationale: Yogurt can help reduce problems with flatus in patients with a colostomy.

5. The client with Crohn’s disease has a nursing diagnosis of acute pain. The nurse would teach the client to avoid which of the following in managing this problem?

• A. Lying supine with the legs straight
• B. Massaging the abdomen
• C. Using antispasmodic medication
• D. Using relaxation techniques

Correct answer: A

Rationale: Lying supine with the legs straight can increase abdominal tension and exacerbate pain. The client should be advised to lie with the legs bent to reduce muscle tension and discomfort.

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