Nursing Elites

1. Which of the following treatments is used for rectal cancer but not for colon cancer?

• A. Chemotherapy
• B. Colonoscopy
• C. Radiation
• D. Surgical resection

Correct answer: C

Rationale: Radiation therapy is commonly used for rectal cancer to shrink the tumor before surgery, which is not typically done for colon cancer.

2. Vasopressin (Pitressin) therapy is prescribed for a client with a diagnosis of bleeding esophageal varices. The nurse is preparing to administer the medication to the client. Which of the following essential items is needed during the administration of this medication?

• A. A cardiac monitor
• B. An intubation set
• C. A suction setup
• D. A tracheotomy set

Correct answer: A

Rationale: The major action of vasopressin is constriction of the splanchnic blood flow. Continuous electrocardiogram and blood pressure monitoring are essential because of the constrictive effects of the medication on the coronary arteries. Options 2, 3, and 4 are not essential items required during the administration of this medication.

3. A Penrose drain is in place on the first postoperative day following a cholecystectomy. Serosanguineous drainage is noted on the dressing covering the drain. Which nursing intervention is most appropriate?

• A. Notify the physician.
• B. Change the dressing.
• C. Circle the amount on the dressing with a pen.
• D. Continue to monitor the drainage.

Correct answer: B

Rationale: Serosanguineous drainage with a small amount of bile is expected from the Penrose drain for the first 24 hours. Drainage then decreases, and the drain is removed usually within 48 hours. The nurse does not need to notify the physician. A sterile dressing covers the site and should be changed to prevent infection and skin excoriation.

4. Which of the following tasks should be included in the immediate postoperative management of a client who has undergone gastric resection?

• A. Monitoring gastric pH to detect complications
• B. Assessing for bowel sounds
• C. Providing nutritional support
• D. Monitoring for symptoms of hemorrhage

Correct answer: D

Rationale: Monitoring for symptoms of hemorrhage is a crucial part of the immediate postoperative management of a client who has undergone gastric resection.

5. 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.

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