NURSING 112023 FUNDAMENTALS TEST
PAPER QUESTIONS AND SOLUTIONS
VERIFIED ANSWERS
●● Christine Warren, 45 years old, has a long history of ulcerative
colitis, and non-surgical treatment no longer relieved her symptoms. She
underwent a total proctocolectomy and a permanent ileostomy 12 hours
ago.
The nurse should contact the physician immediately if Mrs. Warren has
which of these findings?
1) The stoma appears pale and dry.
2) The stoma appears red and shiny.
3) There is 200 mL of dark green output from the stoma.
4) There is 50 mL of serosanguinous drainage from the stoma.
Answer: 1) The stoma appears pale and dry.
Rationale: If there is an adequate blood supply to the stoma, the color is
pink or red, and the stoma is moist as a result of mucous production. A
pale dry color suggests ischemia of the stoma or bowel and must be
reported immediately to the physician. With an ileostomy initially after
surgery, the output is a loose, dark green liquid that may contain some
blood. The ileostomy usually begins to drain within 24 of surgery at
more than one liter per day.
,●● When changing Mrs. Warren's ileostomy bag, the nurse notices that
the peristomal skin is irritated.
Which of these actions by the nurse would be appropriate before
reapplying the appliance?
1) Wash the area with antiseptic soap and water.
2) Clean the site with Dakin's solution.
3) Use a solid skin barrier.
4) Obtain an order for a topical antibiotic.
Answer: 3) Use a solid skin barrier.
Rationale: The drainage from the stoma can quickly irritate the
surrounding tissue. Therefore, a solid skin barrier, with a pectin base or
karaya wafer that has a measurable thickness and hydrocolloid adhesive
properties, should be applied.
●● Which of these comments, if made by Mrs. Warren before her
surgery, would indicate that she had concerns about her body image?
1) "I will have to stop my aerobics classes."
2) "I'm so afraid I may not survive the surgery."
3) "I need to go shopping for some loose, baggy clothes."
4) "I'm concerned that this may be only the first of many surgeries."
,Answer: 3) "I need to go shopping for some loose, baggy clothes."
Rationale:Body image refers to a person's perception of self and
determines how the person interacts with others. One does not need to
purchase special clothing after ileostomy surgery, although some minor
adjustments may be needed for comfort, e.g., stretch underwear or
pantyhose for support.
●● To get TEST BANK for Medical-Surgical Nursing: Concepts for
Clinical Judgment and Collaborative Care 11th Edition by Donna D.
Ignatavicius, All chapters 1 - 74
email or copy these links to get the full
test banks. Each link has a different versions
http://www.stuvia.com/doc/7290675
http://www.stuvia.com/doc/8342084
http://www.stuvia.com/doc/9267657
http://www.stuvia.com/doc/7153071
http://www.stuvia.com/doc/7069048
, Answer: http://www.stuvia.com/doc/7290675
●● Lewis Palmer, 45 years old, has a history of multiple myocardial
infarctions and is a heavy smoker. He takes warfarin sodium (Coumadin)
daily. Two weeks ago, he had a right femoral-popliteal bypass, which
became occluded 24 hours ago. He is admitted following an angioplasty
of the femoral-popliteal bypass graft. Mr. Palmer is receiving continuous
IV heparin.
Because Mr. Palmer is receiving heparin, it is essential for the nurse to
1) monitor his prothrombin time.
2) observe him for signs of pulmonary embolism.
3) limit his intake of foods high in vitamin K.
4) check the femoral puncture site at frequent intervals.
Answer: 4) check the femoral puncture site at frequent intervals.
Rationale: Since bleeding is a common side effect of heparin, it is vital
to check the operative site, the femoral puncture area, for signs of
bleeding.
●● Attempts to revascularize Mr. Palmer's leg are unsuccessful, and Mr.
Palmer has a below-knee amputation (BKA) of his right extremity and is
returned to the medical-surgical unit with an intravenous infusion in
place. His orders include: heparin drip, morphine sulfate 10 mg IV push
q4h prn for pain, and ampicillin sodium g 1 IV q6h.
PAPER QUESTIONS AND SOLUTIONS
VERIFIED ANSWERS
●● Christine Warren, 45 years old, has a long history of ulcerative
colitis, and non-surgical treatment no longer relieved her symptoms. She
underwent a total proctocolectomy and a permanent ileostomy 12 hours
ago.
The nurse should contact the physician immediately if Mrs. Warren has
which of these findings?
1) The stoma appears pale and dry.
2) The stoma appears red and shiny.
3) There is 200 mL of dark green output from the stoma.
4) There is 50 mL of serosanguinous drainage from the stoma.
Answer: 1) The stoma appears pale and dry.
Rationale: If there is an adequate blood supply to the stoma, the color is
pink or red, and the stoma is moist as a result of mucous production. A
pale dry color suggests ischemia of the stoma or bowel and must be
reported immediately to the physician. With an ileostomy initially after
surgery, the output is a loose, dark green liquid that may contain some
blood. The ileostomy usually begins to drain within 24 of surgery at
more than one liter per day.
,●● When changing Mrs. Warren's ileostomy bag, the nurse notices that
the peristomal skin is irritated.
Which of these actions by the nurse would be appropriate before
reapplying the appliance?
1) Wash the area with antiseptic soap and water.
2) Clean the site with Dakin's solution.
3) Use a solid skin barrier.
4) Obtain an order for a topical antibiotic.
Answer: 3) Use a solid skin barrier.
Rationale: The drainage from the stoma can quickly irritate the
surrounding tissue. Therefore, a solid skin barrier, with a pectin base or
karaya wafer that has a measurable thickness and hydrocolloid adhesive
properties, should be applied.
●● Which of these comments, if made by Mrs. Warren before her
surgery, would indicate that she had concerns about her body image?
1) "I will have to stop my aerobics classes."
2) "I'm so afraid I may not survive the surgery."
3) "I need to go shopping for some loose, baggy clothes."
4) "I'm concerned that this may be only the first of many surgeries."
,Answer: 3) "I need to go shopping for some loose, baggy clothes."
Rationale:Body image refers to a person's perception of self and
determines how the person interacts with others. One does not need to
purchase special clothing after ileostomy surgery, although some minor
adjustments may be needed for comfort, e.g., stretch underwear or
pantyhose for support.
●● To get TEST BANK for Medical-Surgical Nursing: Concepts for
Clinical Judgment and Collaborative Care 11th Edition by Donna D.
Ignatavicius, All chapters 1 - 74
email or copy these links to get the full
test banks. Each link has a different versions
http://www.stuvia.com/doc/7290675
http://www.stuvia.com/doc/8342084
http://www.stuvia.com/doc/9267657
http://www.stuvia.com/doc/7153071
http://www.stuvia.com/doc/7069048
, Answer: http://www.stuvia.com/doc/7290675
●● Lewis Palmer, 45 years old, has a history of multiple myocardial
infarctions and is a heavy smoker. He takes warfarin sodium (Coumadin)
daily. Two weeks ago, he had a right femoral-popliteal bypass, which
became occluded 24 hours ago. He is admitted following an angioplasty
of the femoral-popliteal bypass graft. Mr. Palmer is receiving continuous
IV heparin.
Because Mr. Palmer is receiving heparin, it is essential for the nurse to
1) monitor his prothrombin time.
2) observe him for signs of pulmonary embolism.
3) limit his intake of foods high in vitamin K.
4) check the femoral puncture site at frequent intervals.
Answer: 4) check the femoral puncture site at frequent intervals.
Rationale: Since bleeding is a common side effect of heparin, it is vital
to check the operative site, the femoral puncture area, for signs of
bleeding.
●● Attempts to revascularize Mr. Palmer's leg are unsuccessful, and Mr.
Palmer has a below-knee amputation (BKA) of his right extremity and is
returned to the medical-surgical unit with an intravenous infusion in
place. His orders include: heparin drip, morphine sulfate 10 mg IV push
q4h prn for pain, and ampicillin sodium g 1 IV q6h.
