Nursing Elites

1. Which of the following complications of gastric resection should the nurse teach the client to watch for?

• A. Constipation
• B. Dumping syndrome
• C. Gastric spasm
• D. Intestinal spasms

Correct answer: B

Rationale: Clients should be taught to watch for symptoms of dumping syndrome, a common complication after gastric resection.

2. The nurse develops a plan of care for a client with a T tube. Which one of the following nursing interventions should be included?

• A. Inspect skin around the T tube daily for irritation.
• B. Irrigate the T tube every 4 hours to maintain patency.
• C. Maintain the client in a supine position while the T tube is in place.
• D. Keep the T tube clamped except during mealtimes.

Correct answer: A

Rationale: The correct nursing intervention to include in the plan of care for a client with a T tube is to inspect the skin around the T tube daily for irritation. Bile is erosive and can cause skin irritation, so it is crucial to keep the skin clean and dry. T tubes are not routinely irrigated; irrigation is done only with a physician's order. It is unnecessary to maintain the client in a supine position; instead, assist the client into a position of comfort. T tubes are not typically clamped unless ordered by a physician, and if clamped, it is usually done 1 to 2 hours before and after meals.

3. 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.

4. Christina is receiving an enteral feeding that requires a concentration of 80ml of supplement mixed with 20 ml of water. How much water do you mix with an 8 oz (240ml) can of feeding?

• A. 60 ml.
• B. 70 ml.
• C. 80 ml.
• D. 90 ml.

Correct answer: A

Rationale: For an 8 oz (240 ml) can of feeding, mix 60 ml of water to achieve the required concentration.

5. When a client has peptic ulcer disease, the nurse would expect a priority intervention to be:

• A. Assisting in inserting a Miller-Abbott tube
• B. Assisting in inserting an arterial pressure line
• C. Inserting a nasogastric tube
• D. Inserting an I.V.

Correct answer: C

Rationale: Inserting a nasogastric tube is a priority intervention for a client with peptic ulcer disease to decompress the stomach.

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