Nursing Elites

1. Which of the following factors is believed to be linked to Crohn’s disease?

• A. Constipation
• B. Diet
• C. Hereditary
• D. Lack of exercise

Correct answer: C

Rationale: Crohn's disease is believed to have a hereditary link, with genetic factors playing a significant role in its development.

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. Vasopressin (Pitressin) therapy is prescribed for a client with a diagnosis of bleeding esophageal varices. The nurse is preparing to administer the medication to the client. Which of the following essential items is needed during the administration of this medication?

• A. A cardiac monitor
• B. An intubation set
• C. A suction setup
• D. A tracheotomy set

Correct answer: A

Rationale: The major action of vasopressin is constriction of the splanchnic blood flow. Continuous electrocardiogram and blood pressure monitoring are essential because of the constrictive effects of the medication on the coronary arteries. Options 2, 3, and 4 are not essential items required during the administration of this medication.

4. The nurse is performing a colostomy irrigation on a client. During the irrigation, a client begins to complain of abdominal cramps. Which of the following is the most appropriate nursing action?

• A. Notify the physician
• B. Increase the height of the irrigation
• C. Stop the irrigation temporarily.
• D. Medicate with dilaudid and resume the irrigation

Correct answer: C

Rationale: If a client experiences abdominal cramps during a colostomy irrigation, it is appropriate to stop the irrigation temporarily to allow the cramps to subside.

5. Your teaching Anthony how to use his new colostomy. How much skin should remain exposed between the stoma and the ring of the appliance?

• A. 1/16”
• B. 1/4″
• C. 1/2”
• D. 1”

Correct answer: A

Rationale: When teaching a patient how to use a colostomy, only 1/16” of skin should remain exposed between the stoma and the ring of the appliance to prevent skin irritation.

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