Nursing Elites

1. A nurse is developing a plan of care for a client who will be returning to a nursing unit following a percutaneous transhephatic cholangiogram. The nurse includes which intervention in the postprocedure plan of care?

• A. Place a sandbag over the insertion site.
• B. Allow the client bathroom privileges only.
• C. Encourage fluid intake.
• D. Allow the client to sit in a chair for meals.

Correct answer: A

Rationale: Following this procedure, the nurse monitors the client’s vital signs closely for indications of hemorrhage and observes the needle insertion site for bleeding and bile leakage. A sandbag is placed over the insertion site to prevent bleeding. The client is maintained on bedrest, and oral intake is avoided in the immediate postprocedure period in case surgery is necessary to control hemorrhage of bile extravasation.

2. When teaching a community group about measures to prevent colon cancer, which instruction should the nurse include?

• A. Limit fat intake to 20% to 25% of your total daily calories.
• B. Include 15 to 20 grams of fiber into your daily diet.
• C. Get an annual rectal examination after age 35.
• D. Undergo sigmoidoscopy annually after age 50.

Correct answer: A

Rationale: Limiting fat intake is a recommended measure to reduce the risk of colon cancer. Including fiber, undergoing annual rectal examinations, and sigmoidoscopy are also important, but limiting fat intake is directly related to reducing cancer risk.

3. The client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate post-op period for which of the following most frequent complications of this type of surgery?

• A. Intestinal obstruction
• B. Fluid and electrolyte imbalance
• C. Malabsorption of fat
• D. Folate deficiency

Correct answer: B

Rationale: Fluid and electrolyte imbalance is a common complication following ileostomy surgery due to the loss of large volumes of fluid and electrolytes through the stoma. Monitoring and replacing fluids and electrolytes is essential.

4. You’re assessing the stoma of a patient with a healthy, well-healed colostomy. You expect the stoma to appear:

• A. Pale, pink and moist
• B. Red and moist
• C. Dark or purple colored
• D. Dry and black

Correct answer: B

Rationale: A healthy, well-healed colostomy stoma should appear red and moist.

5. Vasopressin (Pitressin) therapy is prescribed for a client with a diagnosis of bleeding esophageal varices. The nurse is preparing to administer the medication to the client. Which of the following essential items is needed during the administration of this medication?

• A. A cardiac monitor
• B. An intubation set
• C. A suction setup
• D. A tracheotomy set

Correct answer: A

Rationale: The major action of vasopressin is constriction of the splanchnic blood flow. Continuous electrocardiogram and blood pressure monitoring are essential because of the constrictive effects of the medication on the coronary arteries. Options 2, 3, and 4 are not essential items required during the administration of this medication.

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