Nursing Elites

1. The nurse is irrigating a client's colostomy when she complains of abdominal cramping after receiving about 100 mL of the irrigating solution. What should the nurse's first response be in this situation?

• A. Stop the flow of solution temporarily.
• B. Reposition the client on to her right side.
• C. Remove the irrigation tube.
• D. Massage the abdomen gently.

Correct answer: A

Rationale: The abdominal cramping that can occur during colostomy irrigation results from stimulation of the colon by the irrigating solution. The nurse's first response should be to temporarily stop the flow of solution to allow the cramping to subside. Repositioning the client to the right side will not alleviate the cramping. Removing the tube will not decrease the cramping and will necessitate reinsertion of the tube when the irrigation is resumed. Massaging the abdomen gently may be soothing to some clients, but it is not the nurse's first priority action.

2. Britney, a 20 y.o. student is admitted with acute pancreatitis. Which laboratory findings do you expect to be abnormal for this patient?

• A. Serum creatinine and BUN
• B. Alanine aminotransferase (ALT) and aspartate aminotransferase (AST)
• C. Serum amylase and lipase
• D. Cardiac enzymes

Correct answer: C

Rationale: Serum amylase and lipase levels are typically elevated in patients with acute pancreatitis.

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. A client with gastric cancer may exhibit which of the following symptoms?

• A. Abdominal cramping
• B. Constant hunger
• C. Feeling of fullness
• D. Weight gain

Correct answer: C

Rationale: Clients with gastric cancer may experience a feeling of fullness due to the presence of the tumor.

5. The client with a colostomy has an order for irrigation of the colostomy. The nurse uses which solution for the irrigation?

• A. Distilled water
• B. Tap water
• C. Sterile water
• D. Lactated Ringer’s

Correct answer: B

Rationale: The correct solution to use for the irrigation of a colostomy is warm tap water or saline solution. If tap water is not suitable for drinking, bottled water can be used. Distilled water, sterile water, and Lactated Ringer’s are not appropriate solutions for colostomy irrigation. Distilled water lacks essential minerals, sterile water may not provide adequate cleaning, and Lactated Ringer’s is not indicated for this procedure.

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