Nursing Elites

1. A nurse is inserting a nasogastric tube in an adult client. During the procedure, the client begins to cough and has difficulty breathing. Which of the following is the most appropriate nursing action?

• A. Remove the tube and reinsert when the respiratory distress subsides.
• B. Pull back on the tube and wait until the respiratory distress subsides.
• C. Quickly insert the tube.
• D. Notify the physician immediately.

Correct answer: B

Rationale: During the insertion of a nasogastric tube, if the client experiences difficulty breathing or any respiratory distress, withdraw the tube slightly, stop the tube advancement, and wait until the distress subsides. Options 1 and 4 are unnecessary. Quickly inserting the tube is not an appropriate action because, in this situation, it may be likely that the tube has entered the bronchus.

2. The nurse has given instructions to the client with an ileostomy about foods to eat to thicken the stool. The nurse determines that the client needs further instructions if the client stated to eat which of the following foods to make the stool less watery?

• A. Pasta
• B. Boiled rice
• C. Bran
• D. Low-fat cheese

Correct answer: C

Rationale: Foods that help to thicken the stool of the client with an ileostomy include pasta, boiled rice, and low-fat cheese. Bran is high in dietary fiber and thus will increase the output of watery stool by increasing propulsion through the bowel. Ileostomy output is liquid. Addition or elimination of various foods can help to thicken or loosen this liquid drainage.

3. The nurse evaluates the client’s stoma during the initial post-op period. Which of the following observations should be reported immediately to the physician?

• A. The stoma is slightly edematous
• B. The stoma is dark red to purple
• C. The stoma oozes a small amount of blood
• D. The stoma does not expel stool

Correct answer: B

Rationale: A dark red to purple stoma may indicate compromised blood flow or ischemia, which requires immediate medical attention. This color change could be a sign of inadequate blood supply to the stoma tissue, leading to tissue damage or necrosis. Reporting this observation promptly is crucial to prevent further complications. Choices A, C, and D are not indicative of immediate medical concern. A slightly edematous stoma, oozing a small amount of blood, or not expelling stool may not be uncommon findings during the initial post-op period and can be managed without urgent intervention.

4. A nurse is assigned to a 40-year-old client who has a diagnosis of chronic pancreatitis. The nurse reviews the laboratory result, anticipating a laboratory report that indicates a serum amylase level of

• A. 45 units/L
• B. 100 units/L
• C. 300 units/L
• D. 500 units/L

Correct answer: C

Rationale: The normal serum amylase level is 25 to 151 IU/L. With chronic cases of pancreatitis, the rise in serum amylase levels usually does not exceed three times the normal value. In acute pancreatitis, the value may exceed five times the normal value. Options 1 and 2 are within normal limits. Option 3 is an extremely elevated level seen in acute pancreatitis.

5. Which of the following areas is the most common site of fistulas in clients with Crohn’s disease?

• A. Anorectal
• B. Ileum
• C. Rectovaginal
• D. Transverse colon

Correct answer: A

Rationale: The anorectal area is the most common site of fistulas in clients with Crohn's disease.

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