Nursing Elites

1. You’re patient is complaining of abdominal pain during assessment. What is your priority?

• A. Auscultate to determine changes in bowel sounds.
• B. Observe the contour of the abdomen.
• C. Palpate the abdomen for a mass.
• D. Percuss the abdomen to determine if fluid is present.

Correct answer: A

Rationale: When a patient is complaining of abdominal pain, the priority is to auscultate to determine changes in bowel sounds.

2. An enema is prescribed for a client with suspected appendicitis. Which of the following actions should the nurse take?

• A. Prepare 750 ml of irrigating solution warmed to 100*F
• B. Question the physician about the order
• C. Provide privacy and explain the procedure to the client
• D. Assist the client to left lateral Sim’s position

Correct answer: B

Rationale: An enema is contraindicated in clients with suspected appendicitis because it can increase the risk of perforation. It is important to verify the appropriateness of this order with the physician.

3. You’re assessing the stoma of a patient with a healthy, well-healed colostomy. You expect the stoma to appear:

• A. Pale, pink and moist
• B. Red and moist
• C. Dark or purple colored
• D. Dry and black

Correct answer: B

Rationale: A healthy, well-healed colostomy stoma should appear red and moist.

4. The nurse is caring for a client who has had a gastroscopy. Which of the following symptoms may indicate that the client is developing a complication related to the procedure? Select all that apply.

• A. The client complains of a sore throat
• B. The client has a temperature of 100*F
• C. The client appears drowsy following the procedure
• D. The client complains of epigastric pain

Correct answer: B

Rationale: A temperature of 100°F, epigastric pain, and hematemesis are signs that may indicate a complication related to the gastroscopy procedure.

5. You’re preparing a teaching plan for a 27 y.o. named Jeff who underwent surgery to close a temporary ileostomy. Which nutritional guideline do you include in this plan?

• A. There is no need to change eating habits.
• B. Eat six small meals a day.
• C. Eat the largest meal in the evening.
• D. Restrict fluid intake.

Correct answer: B

Rationale: After ileostomy closure surgery, it is recommended to eat six small meals a day to aid digestion and absorption.

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