Nursing Elites

1. 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.

2. 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.

3. Brenda, a 36 y.o. patient is on your floor with acute pancreatitis. Treatment for her includes:

• A. Continuous peritoneal lavage.
• B. Regular diet with increased fat.
• C. Nutritional support with TPN.
• D. Insertion of a T tube to drain the pancreas.

Correct answer: C

Rationale: Treatment for acute pancreatitis includes nutritional support with TPN.

4. The client who has undergone creation of a colostomy has a nursing diagnosis of Disturbed body image. The nurse would evaluate that the client is making the most significant progress toward identified goals if the client:

• A. Watches the nurse empty the colostomy bag
• B. Looks at the ostomy site
• C. Reads the ostomy product literature
• D. Practices cutting the ostomy appliance

Correct answer: D

Rationale: The correct answer is D: Practices cutting the ostomy appliance. This choice indicates that the client is actively involved in self-care and adapting to the colostomy. By practicing cutting the ostomy appliance, the client is demonstrating independence and self-management skills, showing significant progress towards overcoming the disturbed body image. Choices A, B, and C do not involve active participation in self-care tasks related to the colostomy, which are essential for the client's adaptation and acceptance.

5. A client has just had surgery for colon cancer. Which of the following disorders might the client develop?

• A. Peritonitis
• B. Diverticulosis
• C. Partial bowel obstruction
• D. Complete bowel obstruction

Correct answer: C

Rationale: After surgery for colon cancer, the client may develop a partial bowel obstruction.

Similar Questions