A patient is transferred from the recovery room to a surgical unit after a transverse colostomy. The nurse observes the stoma to be deep pink with edema and a small amount of sanguineous drainage. What action should the nurse take?

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Question 1 of 5

A patient is transferred from the recovery room to a surgical unit after a transverse colostomy. The nurse observes the stoma to be deep pink with edema and a small amount of sanguineous drainage. What action should the nurse take?

Correct Answer: D

Rationale: The correct answer is D: Document stoma assessment findings. The rationale for this choice is that documentation is crucial in providing a clear and accurate record of the stoma's condition for ongoing monitoring and evaluation. By documenting the stoma assessment findings, the nurse can track any changes in color, edema, or drainage over time, which helps in identifying any potential issues or improvements. Choice A is incorrect because placing ice packs around the stoma can cause vasoconstriction and worsen the edema. Choice B is unnecessary at this point as the nurse can first assess and document the stoma before escalating to the surgeon if needed. Choice C is not the best action as monitoring every 30 minutes may be excessive and not practical, especially if the patient is stable.

Question 2 of 5

The buildup of bile pigment in tissues that can be caused by gallstones is _____.

Correct Answer: B

Rationale: The correct answer is B: obstructive jaundice. Gallstones can obstruct the bile duct, leading to the buildup of bile pigment in tissues, causing jaundice. This results in the characteristic yellowing of the skin and eyes. Hyperbilirubinemia (A) refers to elevated levels of bilirubin in the blood, which can occur in various liver conditions. Hepatitis (C) is inflammation of the liver, which can also lead to jaundice but is not directly caused by gallstones. Hepatocellular jaundice (D) is due to liver cell damage, not bile duct obstruction.

Question 3 of 5

The ileocecal valve prevents chyme from entering the _____.

Correct Answer: A

Rationale: The correct answer is A: large intestine. The ileocecal valve is located between the ileum (part of the small intestine) and the cecum (part of the large intestine). Its primary function is to prevent the backflow of contents from the large intestine into the small intestine, specifically preventing chyme from entering the large intestine prematurely. This allows for proper digestion and absorption of nutrients in the small intestine before the remaining waste material enters the large intestine for further processing. Choices B, C, and D are incorrect as the ileocecal valve specifically regulates the flow of material between the small and large intestines, not other parts of the digestive system such as the stomach or duodenum.

Question 4 of 5

Which of the following hydrolytic enzymes act in low pH?

Correct Answer: D

Rationale: The correct answer is D: Proteases. Proteases are enzymes that break down proteins, and they are known to function optimally in low pH environments, such as the acidic environment of the stomach. This is because the acidic pH helps in the activation and stability of proteases, allowing them to efficiently break down proteins into smaller peptides and amino acids. Rationale for why the other choices are incorrect: A: Peroxidases catalyze oxidation reactions and are not specifically known to act in low pH environments. B: Hydrolases are a broad category of enzymes that catalyze the hydrolysis of various molecules but are not specifically tailored for low pH conditions. C: Amylases are enzymes that break down carbohydrates and typically work best in neutral to slightly alkaline pH conditions, not in low pH environments like proteases.

Question 5 of 5

A nurse is teaching a client about strategies to manage gastroesophageal reflux disease (GERD). Which of the following statements should the nurse include?

Correct Answer: D

Rationale: The correct answer is D: Avoid eating 2 to 3 hours before bedtime. This is because lying down after eating can worsen GERD symptoms by allowing stomach acid to flow back up into the esophagus. By avoiding eating close to bedtime, the client can reduce the risk of acid reflux. A: Elevating the head of the bed helps reduce nighttime symptoms, but it is not the most essential strategy. B: Avoiding snacking between meals can help, but the timing of meals is more crucial for managing GERD. C: Limiting foods high in fiber is not directly related to managing GERD; it is more about avoiding trigger foods like citrus, caffeine, and fatty foods.

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