Nursing Elites

1. 24 hours after the creation of a colostomy, what should Nurse Violy identify as the normal appearance of the stoma?

• A. Pink, moist, and slightly protruding from the abdomen
• B. Gray, moist, and slightly protruding from the abdomen
• C. Pink, dry, and slightly protruding from the abdomen
• D. Red, moist, and slightly protruding from the abdomen

Correct answer: A

Rationale: Following colostomy surgery, a healthy stoma should appear pink, moist, and slightly protruding from the abdomen, which is why option 'A' is the correct answer. A gray stoma (choice 'B') could indicate poor blood supply or necrosis, which is a serious complication. A dry stoma (choice 'C') is also not normal as it should be moist; a dry stoma may suggest dehydration or other complications. While a stoma can appear red (choice 'D'), this is not typically the normal color; it should usually be pink. Therefore, it's important for healthcare professionals to correctly identify the normal and abnormal appearances of a stoma to ensure proper patient care.

2. You are teaching your clients the difference between Type I (IDDM) and Type II (NDDM) diabetes. Which of the following statements is true?

• A. Both types of diabetes mellitus clients are prone to developing ketosis.
• B. Type II (NIDDM) is more common and preventable compared to Type I (IDDM) diabetes, which is genetic.
• C. Type I (IIDM) is characterized by fasting hyperglycemia.
• D. Type II (NIDDM) is characterized by abnormal immune response.

Correct answer: D

Rationale: The correct answer is D. Type II diabetes (NIDDM) is characterized by insulin resistance and a relative lack of insulin. It is not primarily characterized by an abnormal immune response. Option A is incorrect because only Type I diabetes clients are prone to developing ketosis due to a lack of insulin. Option B is incorrect because while Type II diabetes is more common and often preventable through lifestyle changes, it is not solely genetic. Option C is incorrect because Type I diabetes, not Type II, is characterized by fasting hyperglycemia due to an absolute lack of insulin production.

3. An essential nutrient must:

• A. be eaten every day
• B. be obtained by the diet
• C. be water soluble
• D. be eaten at every meal

Correct answer: B

Rationale: The correct answer is B: 'be obtained by the diet.' Essential nutrients are those that the body cannot synthesize in sufficient quantities and must therefore be obtained through the diet. Choice A is incorrect because not all essential nutrients need to be consumed daily; the frequency of consumption varies. Choice C is incorrect because not all essential nutrients are water-soluble; they can be water-soluble or fat-soluble. Choice D is incorrect because essential nutrients do not need to be consumed at every meal, but rather need to be included in the overall diet regularly.

4. The nurse is correct in performing suctioning when she applies the suction intermittently during:

• A. Insertion of the suction catheter
• B. Withdrawing of the suction catheter
• C. both insertion and withdrawing of the suction catheter
• D. When the suction catheter tip reaches the bifurcation of the trachea

Correct answer: B

Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.

5. What is the term for a barrier that prevents the normal emptying of stomach contents into the duodenum?

• A. Dumping syndrome
• B. Gastritis
• C. Gastric outlet obstruction
• D. Hypochlorhydria

Correct answer: C

Rationale: Gastric outlet obstruction refers to a condition where the opening between the stomach and the duodenum is blocked, preventing the normal passage of food. This is why choice 'C' is correct. 'A: Dumping syndrome' is incorrect because it is a condition where stomach contents move too quickly through the small intestine, not a barrier preventing emptying. 'B: Gastritis' is inflammation of the stomach lining, not a blockage of the outlet. 'D: Hypochlorhydria' refers to low stomach acid, which may affect digestion but does not create a physical barrier blocking the outlet of the stomach.

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