Nursing Elites

1. Which of the following symptoms is common with a hiatal hernia?

• A. Left arm pain
• B. Lower back pain
• C. Esophageal reflux
• D. Abdominal cramping

Correct answer: C

Rationale: Esophageal reflux is a common symptom of a hiatal hernia because the hernia can cause stomach acid to move back up into the esophagus.

2. You’re caring for Carin who has just had ileostomy surgery. During the first 24 hours post-op, how much drainage can you expect from the ileostomy?

• A. 100 ml
• B. 500 ml
• C. 1500 ml
• D. 5000 ml

Correct answer: C

Rationale: During the first 24 hours post-op, you can expect about 1500 ml of drainage from the ileostomy.

3. The client with a new colostomy is concerned about the odor from stool from the ostomy drainage bag. The nurse teaches the client to include which of the following foods in the diet to reduce odor?

• A. Yogurt
• B. Broccoli
• C. Cucumbers
• D. Eggs

Correct answer: A

Rationale: The client should be taught to include deodorizing foods in the diet, such as beet greens, parsley, buttermilk, and yogurt. Spinach also reduces odor but is a gas-forming food as well. Broccoli, cucumber, and eggs are gas-forming foods.

4. You’re patient, post-op drainage of a pelvic abscess secondary to diverticulitis, begins to cough violently after drinking water. His wound has ruptured and a small segment of the bowel is protruding. What’s your priority?

• A. Ask the patient what happened, call the doctor, and cover the area with a water-soaked bedsheet.
• B. Obtain vital signs, call the doctor, and obtain emergency orders.
• C. Have a CAN hold the wound together while you obtain vital signs, call the doctor and flex the patient’s knees.
• D. Have the doctor called while you remain with the patient, flex the patient’s knees, and cover the wound with sterile towels soaked in sterile saline solution.

Correct answer: D

Rationale: For a patient with a ruptured wound and protruding bowel, call the doctor while remaining with the patient, flex the patient’s knees, and cover the wound with sterile towels soaked in sterile saline solution.

5. The nurse is planning to teach the client with gastroesophageal reflux disease about substances that will increase the lower esophageal sphincter pressure. Which of the following items would the nurse include on this list?

• A. Fatty foods
• B. Nonfat milk
• C. Chocolate
• D. Coffee

Correct answer: B

Rationale: Foods that increase the lower esophageal sphincter (LES) pressure will decrease reflux, and lessen the symptoms of gastroesophageal reflux disease (GERD). The food substance that will increase the LES pressure is nonfat milk. The other substances listed decrease the LES pressure, thus increasing reflux symptoms. Aggravating substances include chocolate, coffee, fatty foods and alcohol.

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