Nursing Elites

1. 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.

2. The client with peptic ulcer disease is scheduled for a pyloroplasty. The client asks the nurse about the procedure. The nurse plans to respond knowing that a pyloroplasty involves:

• A. Cutting the vagus nerve
• B. Removing the distal portion of the stomach
• C. Removal of the ulcer and a large portion of the cells that produce hydrochloric acid
• D. An incision and resuturing of the pylorus to relax the muscle and enlarge the opening from the stomach to the duodenum.

Correct answer: D

Rationale: A pyloroplasty involves making an incision in the pylorus (the opening from the stomach to the duodenum) and then resuturing it to relax the muscle and enlarge the opening.

3. Rob is a 46 y.o. admitted to the hospital with a suspected diagnosis of Hepatitis B. He’s jaundiced and reports weakness. Which intervention will you include in his care?

• A. Regular exercise.
• B. A low-protein diet.
• C. Allow patient to select his meals.
• D. Rest period after small, frequent meals.

Correct answer: D

Rationale: For a patient with hepatitis B who is jaundiced and reports weakness, providing rest periods after small, frequent meals is important.

4. 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.

5. Donald is a 61 y.o. man with diverticulitis. Diverticulitis is characterized by:

• A. Periodic rectal hemorrhage.
• B. Hypertension and tachycardia.
• C. Vomiting and elevated temperature.
• D. Crampy and lower left quadrant pain and low-grade fever.

Correct answer: D

Rationale: Diverticulitis is characterized by crampy lower left quadrant pain and a low-grade fever.

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