Question set A: the gut and the liver, ten items

Ostomy output by site

A healthy stoma is beefy red and moist. A dusky, purple, or black stoma is reported immediately.

TIMING: 12 minutes

1. A 62-year-old reports coffee-ground emesis this morning and has just passed a black, tarry stool. Blood pressure 92/54, heart rate 118, skin cool. Which action does the nurse take first?

1. Send a stool specimen for occult blood testing
2. Establish large-bore intravenous access and begin the prescribed isotonic fluid
3. Obtain a detailed dietary history from the previous week
4. Place the patient in high Fowler position and offer clear liquids

2. A 70-year-old is passing bright red blood per rectum. Which finding most strongly suggests the bleeding source is proximal to the ligament of Treitz?

1. Blood urea nitrogen rising while creatinine remains unchanged
2. Tenderness in the left lower quadrant
3. A documented history of internal hemorrhoids
4. Mucus mixed through the stool

3. A patient with a known duodenal ulcer develops sudden severe epigastric pain and a rigid, board-like abdomen. Place the nurse's actions in order.

1. Administer the prescribed intravenous antibiotic
2. Obtain a full set of vital signs and assess the abdomen
3. Insert the nasogastric tube to low intermittent suction as prescribed
4. Keep the patient nothing by mouth and stop all oral and enteral intake
5. Notify the surgeon

4. A 19-year-old with suspected appendicitis asks for a heating pad and a laxative because "nothing is moving." Which response is correct?

1. Apply a warm compress to the right lower quadrant for comfort
2. Administer the prescribed enema to relieve the constipation
3. Keep the patient nothing by mouth and withhold heat, enemas, and laxatives
4. Encourage ambulation with the knees fully extended

5. Which cluster best supports small bowel rather than large bowel obstruction?

1. Gradual distension, obstipation, and late feculent vomiting
2. Colicky pain, early bilious vomiting, and high-pitched bowel sounds
3. Painless bright red rectal bleeding with normal bowel sounds
4. Constant epigastric pain relieved by leaning forward

6. A patient admitted with acute pancreatitis develops carpal spasm when the blood pressure cuff is inflated. Select all that apply. Which actions are appropriate?

1. Notify the provider of a positive Trousseau sign
2. Initiate seizure precautions
3. Document the finding as an expected effect of the cuff pressure
4. Assess for facial twitching when the facial nerve is tapped
5. Encourage the patient to lie flat to reduce pain

7. A patient with cirrhosis is being monitored on a medical unit. Select all that apply. Which findings require immediate provider notification?

1. Hand flapping when the wrists are extended
2. Reversal of the day and night sleep pattern beginning today
3. One episode of coffee-ground emesis
4. Abdominal girth unchanged from yesterday at the same landmark
5. Blood pressure of 84/48 one hour after a large-volume paracentesis

8. An unvaccinated nurse sustains a needlestick from a patient known to be positive for hepatitis B surface antigen. Which post-exposure management does the nurse anticipate?

1. Hepatitis B immune globulin plus initiation of the hepatitis B vaccine series
2. Immune globulin alone, with no vaccine indicated
3. Baseline and follow-up testing only, because no prophylaxis exists
4. A single dose of hepatitis A vaccine

9. Hot spot. Using the figure above, mark the stoma site whose output is liquid, enzyme-rich, and highest in volume, and which therefore carries the greatest peristomal skin breakdown and dehydration risk. ☐ Ileostomy ☐ Ascending colostomy ☐ Transverse colostomy ☐ Descending or sigmoid colostomy

10. The patient in item 9 is being discharged. Select all that apply. Which statements indicate correct understanding?

1. "I will cut the appliance opening about one eighth of an inch larger than my stoma."
2. "I will empty the pouch when it is about one third full."
3. "I will call if my output goes above about a liter a day or if I stop passing output and my abdomen cramps."
4. "I will irrigate every morning to get on a schedule."
5. "I will chew popcorn, nuts, and raw celery well for the first several weeks rather than avoiding them."
6. "A little bleeding when I clean the stoma is expected, but a dusky or black stoma means I call right away."

☐1 ☐2 ☐3 ☐4 ☐5 ☐6 ☐7 ☐8 ☐9 ☐10

Margin noteanswer before you look at the figure twice.

Takeawaythe priority action is usually the one that stops a loss, protects an airway, or ends an exposure, and it is rarely the one that gathers more data.

Rationales → BOOK 11 · P13.