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. When planning care for a client with ulcerative colitis who is experiencing symptoms, which client care activities can the nurse appropriately delegate to a unlicensed assistant?

• A. Assessing the client's bowel sounds
• B. Providing skin care following bowel movements
• C. Evaluating the client's response to antidiarrheal medications
• D. administration of pain medication every 4 hours

Correct answer: B

Rationale: Providing skin care following bowel movements, maintaining intake and output records, and obtaining the client's weight can be delegated to a unlicensed assistant.

3. Jerod is experiencing an acute episode of ulcerative colitis. What is the priority for this patient?

• A. Replace lost fluid and sodium.
• B. Monitor for increased serum glucose levels from steroid therapy.
• C. Restrict dietary intake of foods high in potassium.
• D. Note any change in the color and consistency of stools.

Correct answer: A

Rationale: The correct answer is to replace lost fluid and sodium. During an acute episode of ulcerative colitis, the priority is to manage the patient's fluid and electrolyte balance. This is crucial due to the potential for dehydration and electrolyte imbalances resulting from diarrhea and inflammation in the colon. Monitoring serum glucose levels (Choice B) may be important for patients on steroid therapy, but in this scenario, fluid and electrolyte balance take precedence. Restricting dietary intake of foods high in potassium (Choice C) is not a priority in the acute phase of ulcerative colitis. While noting changes in stool color and consistency (Choice D) is important for assessing the patient's gastrointestinal status, it is not the priority when managing acute ulcerative colitis.

4. Which of the following substances is most likely to cause gastritis?

• A. Milk
• B. Bicarbonate of soda or baking soda
• C. Enteric-coated aspirin
• D. Nonsteroidal anti-inflammatory drugs (NSAIDs)

Correct answer: D

Rationale: The correct answer is D, Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs are known to cause gastritis by irritating the stomach lining. Choice A, Milk, is unlikely to cause gastritis and is actually a common remedy for mild gastritis symptoms. Choice B, Bicarbonate of soda or baking soda, is often used to relieve heartburn and indigestion, not cause gastritis. Choice C, Enteric-coated aspirin, is less likely to cause gastritis compared to NSAIDs because the enteric coating helps protect the stomach lining from irritation.

5. Crohn’s disease can be described as a chronic relapsing disease. Which of the following areas in the GI system may be involved with this disease?

• A. The entire length of the large colon
• B. Only the sigmoid area
• C. The entire large colon through the layers of mucosa and submucosa
• D. The small intestine and colon; affecting the entire thickness of the bowel

Correct answer: D

Rationale: Crohn's disease can affect any part of the gastrointestinal tract from the mouth to the anus, but it commonly affects the small intestine and colon, involving the entire thickness of the bowel wall.

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