Nursing Elites

1. You’re doing preoperative teaching with Gertrude who has ulcerative colitis who needs surgery to create an ileoanal reservoir. Which information do you include?

• A. A reservoir is created that exits through the abdominal wall.
• B. A second surgery is required 12 months after the first surgery.
• C. A permanent ileostomy is created.
• D. The surgery occurs in two stages.

Correct answer: D

Rationale: The surgery to create an ileoanal reservoir occurs in two stages.

2. Sitty, a 66 y.o. patient underwent a colostomy for ruptured diverticulum. She did well during the surgery and returned to your med-surg floor in stable condition. You assess her colostomy 2 days after surgery. Which finding do you report to the doctor?

• A. Blanched stoma
• B. Edematous stoma
• C. Reddish-pink stoma
• D. Brownish-black stoma

Correct answer: A

Rationale: A blanched stoma 2 days after colostomy surgery should be reported to the doctor as it may indicate compromised blood flow.

3. The nurse is caring for a client following a Billroth II procedure. On review of the post-operative orders, which of the following, if prescribed, would the nurse question and verify?

• A. Irrigating the nasogastric tube
• B. Coughing a deep breathing exercises
• C. Leg exercises
• D. Early ambulation

Correct answer: A

Rationale: Irrigating the nasogastric tube is typically not recommended after a Billroth II procedure unless specifically ordered by a physician due to the risk of disrupting the surgical site.

4. After a subtotal gastrectomy, care of the client’s nasogastric tube and drainage system should include which of the following nursing interventions?

• A. Irrigate the tube with 30 ml of sterile water every hour, if needed.
• B. Reposition the tube if it is not draining well
• C. Monitor the client for N/V, and abdominal distention
• D. Turn the machine to high suction of the drainage is sluggish on low suction.

Correct answer: C

Rationale: Monitoring the client for nausea, vomiting, and abdominal distention is crucial for ensuring proper functioning of the nasogastric tube and drainage system.

5. The client being treated for esophageal varices has a Sengstaken-Blakemore tube inserted to control the bleeding. The most important assessment is for the nurse to:

• A. Check that the hemostat is on the bedside
• B. Monitor IV fluids for the shift
• C. Regularly assess respiratory status
• D. Check that the balloon is deflated on a regular basis

Correct answer: C

Rationale: Regularly assessing respiratory status is crucial when a Sengstaken-Blakemore tube is inserted to control bleeding in esophageal varices.

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