Nursing Elites

1. A client has a nasogastric tube inserted at the time of abdominal perineal resection with permanent colostomy. This tube will most likely be removed when the client demonstrates:

• A. Absence of nausea and vomiting.
• B. Passage of mucus from the rectum.
• C. Passage of flatus and feces from the colostomy.
• D. Absence of stomach drainage for 24 hours.

Correct answer: C

Rationale: A sign indicating that a client's colostomy is open and ready to function is passage of feces and flatus. When this occurs, gastric suction is ordinarily discontinued, and the client is allowed to start taking fluids and food orally. Absence of bowel sounds would indicate that the tube should remain in place because peristalsis has not yet returned. Absence of nausea and vomiting is not a criterion for judging whether or not gastric suction should be continued. Passage of mucus from the rectum will not occur in this client because the rectum is removed in this surgery. Absence of stomach drainage is not a criterion for judging whether or not gastric suction should be continued.

2. Claire, a 33 y.o. is on your floor with a possible bowel obstruction. Which intervention is priority for her?

• A. Obtain daily weights.
• B. Measure abdominal girth.
• C. Keep strict intake and output.
• D. Encourage her to increase fluids.

Correct answer: B

Rationale: For a patient with a possible bowel obstruction, measuring abdominal girth is a priority to monitor for signs of worsening obstruction or distention.

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. A nurse is reviewing the results of serum laboratory studies drawn on a client who is suspected of having hepatitis. The nurse interprets that an elevation in which of the following studies is the most specific indicator of the disease?

• A. Erythrocyte sedimentation rate
• B. Serum bilirubin
• C. Hemoglobin
• D. Blood urea nitrogen

Correct answer: C

Rationale: Laboratory indicators of hepatitis include elevated liver enzymes, serum bilirubin level, and erythrocyte sedimentation rate is nonspecific test that indicates the presence of inflammation somewhere in the body. Elevated blood urea nitrogen may indicate renal dysfunction. A hemoglobin level is unrelated to this diagnosis.

5. After a subtotal gastrectomy, the nurse should anticipate that nasogastric tube drainage will be what color for about 12 to 24 hours after surgery?

• A. Dark brown
• B. Bile green
• C. Bright red
• D. Cloudy white

Correct answer: A

Rationale: Dark brown drainage is expected for about 12 to 24 hours after surgery.

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