Nursing Elites

1. The nurse is doing preoperative teaching with the client who is about to undergo creation of a Kock pouch. The nurse interprets that the client has the best understanding of the nature of the surgery if the client makes which of the following statements?

• A. I will need to drain the pouch regularly with a catheter.
• B. I will need to wear a drainage bag for the rest of my life.
• C. The drainage from this type of ostomy will be formed.
• D. I will be able to pass stool from the rectum eventually.

Correct answer: A

Rationale: A Kock pouch is a continent ileostomy. As the ileostomy begins to function, the client drains it every 3 to 4 hours and then decreases the draining about 3 times a day or as needed when full. The client does not need to wear a drainage bag but should wear an absorbent dressing to absorb mucous drainage from the stoma. Ileostomy drainage is liquid. The client would be able to pass stool only from the rectum if an ileal-anal pouch or anastomosis were created. This type of operation is a two-stage procedure.

2. Which of the following conditions can cause a hiatal hernia?

• A. Increased intrathoracic pressure
• B. Weakness of the esophageal muscle
• C. Increased esophageal muscle pressure
• D. Weakness of the diaphragmic muscle

Correct answer: D

Rationale: Weakness of the diaphragmic muscle can lead to a hiatal hernia as it allows part of the stomach to push through the diaphragm into the chest cavity.

3. 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.

4. The pain of a duodenal ulcer can be distinguished from that of a gastric ulcer by which of the following characteristics?

• A. Early satiety
• B. Pain on eating
• C. Dull upper epigastric pain
• D. Pain on empty stomach

Correct answer: D

Rationale: Pain on an empty stomach is characteristic of a duodenal ulcer, while pain on eating is characteristic of a gastric ulcer.

5. You’re discharging Nathaniel with hepatitis B. Which statement suggests understanding by the patient?

• A. Now I can never get hepatitis again.
• B. I can safely give blood after 3 months.
• C. I’ll never have a problem with my liver again, even if I drink alcohol.
• D. My family knows that if I get tired and start vomiting, I may be getting sick again.

Correct answer: D

Rationale: Understanding that family needs to be aware of symptoms that may indicate a recurrence of hepatitis B shows proper understanding by the patient.

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