Nursing Elites

1. 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.

2. The nurse is irrigating a client's colostomy when she complains of abdominal cramping after receiving about 100 mL of the irrigating solution. What should the nurse's first response be in this situation?

• A. Stop the flow of solution temporarily.
• B. Reposition the client on to her right side.
• C. Remove the irrigation tube.
• D. Massage the abdomen gently.

Correct answer: A

Rationale: The abdominal cramping that can occur during colostomy irrigation results from stimulation of the colon by the irrigating solution. The nurse's first response should be to temporarily stop the flow of solution to allow the cramping to subside. Repositioning the client to the right side will not alleviate the cramping. Removing the tube will not decrease the cramping and will necessitate reinsertion of the tube when the irrigation is resumed. Massaging the abdomen gently may be soothing to some clients, but it is not the nurse's first priority action.

3. The nurse is doing pre-op teaching with the client who is about to undergo creation of a Kock pouch. The nurse interprets that the client has the best understanding of the nature of the surgery if the client makes which of the following statements?

• A. I will need to drain the pouch regularly with a catheter.
• B. I will need to wear a drainage bag for the rest of my life.
• C. The drainage from this type of ostomy will be formed.
• D. I will be able to pass stool from my rectum eventually.

Correct answer: A

Rationale: A Kock pouch is a type of continent ileostomy that requires catheterization to empty the internal reservoir. Understanding the need for regular catheterization indicates the client comprehends the procedure.

4. Elmer is scheduled for a proctoscopy and has an I.V. The doctor wrote an order for 5mg of I.V. diazepam(Valium). Which order is correct regarding diazepam?

• A. Give diazepam in the I.V. port closest to the vein.
• B. Mix diazepam with 50 ml of dextrose 5% in water and give over 15 minutes.
• C. Give diazepam rapidly I.V. to prevent the bloodstream from diluting the drug mixture.
• D. Question the order because I.V. administration of diazepam is contraindicated.

Correct answer: A

Rationale: The correct method for administering I.V. diazepam is to give it in the I.V. port closest to the vein.

5. Michael, a 42 y.o. man is admitted to the med-surg floor with a diagnosis of acute pancreatitis. His BP is 136/76, pulse 96, Resps 22 and temp 101. His past history includes hyperlipidemia and alcohol abuse. The doctor prescribes an NG tube. Before inserting the tube, you explain the purpose to patient. Which of the following is a most accurate explanation?

• A. It empties the stomach of fluids and gas.
• B. It prevents spasms at the sphincter of Oddi.
• C. It prevents air from forming in the small intestine and large intestine.
• D. It removes bile from the gallbladder.

Correct answer: A

Rationale: Explain to the patient that the NG tube is used to empty the stomach of fluids and gas, which helps relieve symptoms of acute pancreatitis.

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