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. A nurse is caring for a client who has just returned from the operating room following the creation of a colostomy. The nurse is assessing the drainage in the pouch attached to the site where the colostomy was formed and notes serosanguineous drainage. Which nursing action is most appropriate based on this assessment?

• A. Notify the physician
• B. Document the amount and characteristics of the drainage
• C. Apply ice to the stoma site
• D. Apply pressure to the site

Correct answer: B

Rationale: During the first 24 to 72 hours following surgery, mucus and serosanguineous drainage are expected from the stoma. Documenting the amount and characteristics of the drainage is appropriate. The nurse does not need to notify the physician because this is an expected finding. Applying ice or pressure to the site is not necessary.

3. Which of the following symptoms is a client with colon cancer most likely to exhibit?

• A. A change in appetite
• B. A change in bowel habits
• C. An increase in body weight
• D. An increase in body temperature

Correct answer: B

Rationale: A change in bowel habits is the most common symptom of colon cancer.

4. A nurse is giving dietary instructions to a client who has a new colostomy. The nurse encourages the client to eat foods representing which of the following diets for the first 4 to 6 weeks postoperatively?

• A. High-protein
• B. High-carbohydrate
• C. Low-calorie
• D. Low-residue

Correct answer: D

Rationale: For the first 4 to 6 weeks following colostomy formation, the client should take in a low-residue diet. Following this period, the client should eat a high-carbohydrate, high-protein diet. The nurse also instructs the client to add new foods, one at a time, to determine tolerance to that food.

5. A nurse is developing a teaching plan for the client with viral hepatitis. The nurse plans to tell the client which of the following in the teaching session?

• A. Activity should be limited to prevent fatigue
• B. The diet should be low in calories
• C. Meals should be large to conserve energy
• D. Alcohol intake should be limited to 2 oz. per day.

Correct answer: A

Rationale: The client with viral hepatitis should limit activity to avoid fatigue during the recuperation period. The diet should be optimal in calories, proteins, and carbohydrates. The client should take in several small meals per day. Alcohol is strictly forbidden.

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