Nursing Elites

1. Which of the following symptoms would a client in the early stages of peritonitis exhibit?

• A. Abdominal distention
• B. Abdominal pain and rigidity
• C. Hyperactive bowel sounds
• D. Right upper quadrant pain

Correct answer: B

Rationale: In the early stages of peritonitis, the client would exhibit abdominal pain and rigidity due to inflammation.

2. If a gastric acid perforates, which of the following actions should not be included in the immediate management of the client?

• A. Blood replacement
• B. Antacid administration
• C. Nasogastric tube suction
• D. Fluid and electrolyte replacement

Correct answer: B

Rationale: Antacid administration should not be included in the immediate management of a gastric perforation.

3. The nurse is teaching the client how to perform a colostomy irrigation. To enhance the effectiveness of the irrigation and fecal returns, what measure should the nurse instruct the client to do?

• A. Increase fluid intake
• B. Reduce the amount of irrigation solution
• C. Perform the irrigation in the evening
• D. Place heat on the abdomen

Correct answer: A

Rationale: Increasing fluid intake helps to enhance the effectiveness of colostomy irrigation by softening the stool and promoting better fecal return.

4. You’re caring for a patient with a sigmoid colostomy. The stool from this colostomy is:

• A. Formed
• B. Semisolid
• C. Semiliquid
• D. Watery

Correct answer: A

Rationale: The stool from a sigmoid colostomy is typically formed.

5. A nurse teaches a preoperative client about the nasogastric tube that will be inserted in preparation for surgery. The nurse determines that the client understands when the tube will be removed in the postoperative period when the client states

• A. When my gastrointestinal system is healed enough.
• B. When I can tolerate food without vomiting.
• C. When my bowels begin to function again, and I begin to pass gas.
• D. When the doctor says so.

Correct answer: C

Rationale: Nasogastric tubes are discontinued when normal function returns to the gastrointestinal tract. The tube will be removed before gastrointestinal healing. Food would not be administered unless bowel function returns. Although the physician determines when the nasogastric tube will be removed, option 4 does not determine effectiveness of teaching.

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