Nursing Elites

1. When obtaining a nursing history on a client with a suspected gastric ulcer, which signs and symptoms would the nurse expect to see? Select ONE that does not apply.

• A. Epigastric pain at night
• B. Relief of epigastric pain after eating
• C. Vomiting
• D. Weight loss

Correct answer: B

Rationale: Signs and symptoms of a gastric ulcer include epigastric pain at night, vomiting, and weight loss. Relief of epigastric pain after eating is not typically associated with gastric ulcers.

2. The nurse evaluates the client’s stoma during the initial post-op period. Which of the following observations should be reported immediately to the physician?

• A. The stoma is slightly edematous
• B. The stoma is dark red to purple
• C. The stoma oozes a small amount of blood
• D. The stoma does not expel stool

Correct answer: B

Rationale: A dark red to purple stoma may indicate compromised blood flow or ischemia, which requires immediate medical attention. This color change could be a sign of inadequate blood supply to the stoma tissue, leading to tissue damage or necrosis. Reporting this observation promptly is crucial to prevent further complications. Choices A, C, and D are not indicative of immediate medical concern. A slightly edematous stoma, oozing a small amount of blood, or not expelling stool may not be uncommon findings during the initial post-op period and can be managed without urgent intervention.

3. Your patient recently had abdominal surgery and tells you that he feels a popping sensation in his incision during a coughing spell, followed by severe pain. You anticipate an evisceration. Which supplies should you take to his room?

• A. A suture kit.
• B. Sterile water and a suture kit.
• C. Sterile water and sterile dressings.
• D. Sterile saline solution and sterile dressings.

Correct answer: D

Rationale: For a suspected evisceration, sterile saline solution and sterile dressings should be taken to the patient's room to cover the wound and keep it moist.

4. When teaching an elderly client how to prevent constipation, which of the following instructions should the nurse include?

• A. Drink 6 glasses of fluid each day.
• B. Avoid grain products and nuts.
• C. Add at least 4 grams of brain to your cereal each morning.
• D. Be sure to get regular exercise.

Correct answer: D

Rationale: To prevent constipation, elderly clients should be encouraged to get regular exercise, which promotes bowel motility.

5. 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.

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