Nursing Elites

1. 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.

2. You promote hemodynamic stability in a patient with upper GI bleeding by:

• A. Encouraging oral fluid intake.
• B. Monitoring central venous pressure.
• C. Monitoring laboratory test results and vital signs.
• D. Giving blood, electrolyte and fluid replacement.

Correct answer: D

Rationale: Promoting hemodynamic stability in a patient with upper GI bleeding involves giving blood, electrolyte, and fluid replacement.

3. A client’s ulcerative colitis symptoms have been present for longer than 1 week. The nurse recognizes that the client should be assessed carefully for signs of which of the following complications?

• A. Heart failure
• B. DVT
• C. Hypokalemia
• D. Hypocalcemia

Correct answer: C

Rationale: The client should be assessed carefully for signs of hypokalemia, a common complication of prolonged ulcerative colitis symptoms.

4. The client with Crohn’s disease has a nursing diagnosis of acute pain. The nurse would teach the client to avoid which of the following in managing this problem?

• A. Lying supine with the legs straight
• B. Massaging the abdomen
• C. Using antispasmodic medication
• D. Using relaxation techniques

Correct answer: A

Rationale: Lying supine with the legs straight can increase abdominal tension and exacerbate pain. The client should be advised to lie with the legs bent to reduce muscle tension and discomfort.

5. The nurse is caring for a client with cirrhosis. Which manifestations indicate deficient vitamin K absorption caused by this liver disease?

• A. Dyspnea and fatigue
• B. Ascites and orthopnea
• C. Purpura and petechiae
• D. Gynecomastia and testicular atrophy

Correct answer: C

Rationale: A liver disorder, such as cirrhosis, can disrupt the liver's normal use of vitamin K to produce prothrombin (a clotting factor). Because of this, the nurse should monitor the client for signs of bleeding, including purpura and petechiae. Dyspnea and fatigue suggest anemia. Ascites and orthopnea are unrelated to vitamin K absorption. Gynecomastia and testicular atrophy result from decreased estrogen metabolism by the diseased liver.

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