Nursing Elites

1. Which of the following nursing measures would be inappropriate when caring for a client with a Cantor tube?

• A. Injecting 10 mL of air into the tube to facilitate drainage.
• B. Applying a water-soluble lubricant to the client's nares.
• C. Coiling extra tubing on the client's bed.
• D. Irrigating the tube with 50 mL of normal saline solution.

Correct answer: D

Rationale: Intestinal tubes are not irrigated. Injecting air into the tube, applying water-soluble lubricant, and coiling extra tubing are appropriate nursing measures.

2. Which of the following conditions is most likely to directly cause peritonitis?

• A. Cholelithiasis
• B. Gastritis
• C. Perforated ulcer
• D. Incarcerated hernia

Correct answer: C

Rationale: A perforated ulcer is most likely to directly cause peritonitis due to the leakage of gastric contents into the peritoneal cavity.

3. A nurse is caring for a client who has just returned from the operating room following the creation of a colostomy. The nurse is assessing the drainage in the pouch attached to the site where the colostomy was formed and notes serosanguineous drainage. Which nursing action is most appropriate based on this assessment?

• A. Notify the physician
• B. Document the amount and characteristics of the drainage
• C. Apply ice to the stoma site
• D. Apply pressure to the site

Correct answer: B

Rationale: During the first 24 to 72 hours following surgery, mucus and serosanguineous drainage are expected from the stoma. Documenting the amount and characteristics of the drainage is appropriate. The nurse does not need to notify the physician because this is an expected finding. Applying ice or pressure to the site is not necessary.

4. Donald is a 61 y.o. man with diverticulitis. Diverticulitis is characterized by:

• A. Periodic rectal hemorrhage.
• B. Hypertension and tachycardia.
• C. Vomiting and elevated temperature.
• D. Crampy and lower left quadrant pain and low-grade fever.

Correct answer: D

Rationale: Diverticulitis is characterized by crampy lower left quadrant pain and a low-grade fever.

5. Which of the following therapies is not included in the medical management of a client with peritonitis?

• A. Broad-spectrum antibiotics
• B. Electrolyte replacement
• C. I.V. fluids
• D. Regular diet

Correct answer: D

Rationale: A regular diet is not included in the medical management of peritonitis, which requires bowel rest and IV fluids.

Similar Questions