Nursing Elites

1. Your patient with peritonitis is NPO and complaining of thirst. What is your priority?

• A. Increase the I.V. infusion rate.
• B. Use diversion activities.
• C. Provide frequent mouth care.
• D. Give ice chips every 15 minutes.

Correct answer: C

Rationale: The correct answer is C: Provide frequent mouth care. In a patient with peritonitis who is NPO and thirsty, the priority is to maintain oral hygiene and provide comfort by moistening the mouth with frequent mouth care. This helps alleviate the sensation of thirst and maintains oral health. Increasing the IV infusion rate (choice A) may not address the patient's discomfort directly related to thirst. Using diversion activities (choice B) is not as critical as addressing the patient's immediate need for oral care. Giving ice chips every 15 minutes (choice D) is not recommended for a patient with peritonitis who is NPO, as it can lead to complications or worsen the condition.

2. Which of the following factors is believed to cause ulcerative colitis?

• A. Acidic diet
• B. Altered immunity
• C. Chronic constipation
• D. Emotional stress

Correct answer: B

Rationale: Ulcerative colitis is believed to be caused by an altered immune response in the gastrointestinal tract.

3. Regina is a 46 y.o. woman with ulcerative colitis. You expect her stools to look like:

• A. Watery and frothy.
• B. Bloody and mucoid.
• C. Firm and well-formed.
• D. Alternating constipation and diarrhea.

Correct answer: B

Rationale: Stools in ulcerative colitis are typically bloody and mucoid.

4. Your teaching Anthony how to use his new colostomy. How much skin should remain exposed between the stoma and the ring of the appliance?

• A. 1/16”
• B. 1/4″
• C. 1/2”
• D. 1”

Correct answer: A

Rationale: When teaching a patient how to use a colostomy, only 1/16” of skin should remain exposed between the stoma and the ring of the appliance to prevent skin irritation.

5. 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.

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