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

Correct Answer: A

Rationale: In colostomy care, it is essential to ensure that the stoma is properly cared for to prevent complications. The correct answer, A) 1/16", is the ideal amount of skin that should remain exposed between the stoma and the ring of the appliance. This minimal exposure helps to prevent skin irritation, injury, and pressure on the stoma, allowing for optimal stoma function and proper appliance sealing. Option B) 1/4″, C) 1/2", and D) 1" all have too much space between the stoma and the appliance ring. Too much exposed skin can lead to leakage, skin breakdown, and poor adherence of the appliance, increasing the risk of infection and discomfort for the patient. Educationally, understanding the correct amount of skin exposure around a stoma is crucial for nursing students caring for patients with colostomies. Proper stoma care not only ensures the physical well-being of the patient but also promotes their emotional and psychological adjustment to living with a colostomy. Students must be able to apply this knowledge in clinical practice to provide safe and effective care for patients with ostomies.

Correct Answer: C

Rationale: In this scenario, the preferred method of feeding for a patient with the inability to swallow foods but with a functioning GI tract is Nasogastric (NG) feeding, which is option C. NG feeding involves the insertion of a tube through the nose into the stomach, allowing for the delivery of liquid nutrition directly into the gastrointestinal system. The correct answer is NG feeding because it bypasses the oral route while still utilizing the patient's functional GI tract for absorption of nutrients. This method helps maintain the integrity of the GI system and prevents complications associated with total parenteral nutrition (TPN) and peripheral parenteral nutrition (PPN), which are options A and B, respectively. TPN and PPN are reserved for patients who cannot tolerate enteral feeding or have non-functional GI tracts. Oral liquid supplements (option D) are not suitable for this patient as they cannot swallow foods effectively. From an educational perspective, understanding the rationale behind choosing NG feeding in this situation highlights the importance of considering the most appropriate and least invasive method of providing nutrition to patients with specific feeding requirements based on their clinical condition. It also emphasizes the significance of maintaining GI function whenever possible to support overall patient well-being and prevent complications associated with alternative feeding methods.

Correct Answer: A

Rationale: In the context of medical-surgical nursing and gastrointestinal system assessment, the correct priority when a patient complains of abdominal pain is option A) Auscultate to determine changes in bowel sounds. The rationale behind this choice is that changes in bowel sounds can provide crucial information about the functioning of the gastrointestinal tract. Auscultation allows the nurse to assess for the presence or absence of bowel sounds, which can indicate issues such as obstruction, peritonitis, or ileus. Absent bowel sounds may suggest a serious condition requiring immediate intervention. The other options are not the priority because: - Option B) Observing the contour of the abdomen can provide information about distention or abnormal masses, but assessing bowel sounds is more indicative of immediate gastrointestinal function. - Option C) Palpating the abdomen for a mass should only be done after assessing bowel sounds, as palpation can exacerbate pain or discomfort in certain conditions. - Option D) Percussing the abdomen for fluid is not the initial priority when a patient presents with abdominal pain, as auscultation provides more specific information related to gastrointestinal function. Educationally, understanding the rationale behind prioritizing auscultation in assessing abdominal pain reinforces the importance of systematic and evidence-based nursing assessment. It highlights the need for nurses to prioritize assessments based on the urgency of the situation and the potential impact on patient outcomes.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Lower the height of the enema container. Intestinal cramps during enema administration can indicate that the solution is flowing too quickly or with too much force into the intestines. Lowering the height of the enema container will reduce the rate of flow, alleviating the cramps and making the procedure more tolerable for the patient. Discontinuing the procedure (Option A) without addressing the cause of cramps may not be necessary if the issue can be resolved by adjusting the flow rate. Completing the procedure as quickly as possible (Option C) may exacerbate the cramps and cause discomfort for the patient. Continuing administration without adjustments (Option D) can lead to increased discomfort and potential harm to the patient. Educationally, understanding the importance of monitoring patient responses during procedures like enema administration is crucial for nurses. It is essential to recognize signs of discomfort and know how to intervene appropriately to ensure patient safety and comfort. Lowering the enema container height is a simple yet effective intervention that can make a significant difference in the patient's experience.

Correct Answer: D

Rationale: In this scenario, the correct answer is option D: "Stools are less fatty and decreased in frequency." This observation indicates that the treatment with pancrelipase (Viokase) for chronic pancreatitis is effective. Pancrelipase is an enzyme replacement therapy that helps in the digestion of fats, proteins, and carbohydrates by providing the necessary enzymes that the pancreas is unable to produce in sufficient quantities due to pancreatitis. When the stools are less fatty and decreased in frequency, it signifies that the pancrelipase is aiding in the proper digestion and absorption of fats, which is a key indicator of treatment effectiveness in chronic pancreatitis. This observation reflects that the patient's malabsorption issues are improving, leading to better nutritional status and overall health. Option A, "There is no skin breakdown," is not directly related to the effectiveness of pancrelipase therapy for chronic pancreatitis. While malabsorption issues can lead to nutritional deficiencies that may impact skin health, the absence of skin breakdown alone does not specifically indicate the effectiveness of pancrelipase therapy. Option B, "Her appetite improves," is a general and non-specific observation that may not directly correlate with the effectiveness of pancrelipase therapy. While improved appetite can be a positive sign, it does not provide a direct measure of the digestive function and absorption of nutrients, which are the primary goals of pancrelipase therapy. Option C, "She loses more than 10 lbs," is actually a negative outcome in this context. Weight loss in a patient with chronic pancreatitis can indicate ongoing malabsorption and inadequate digestion of nutrients, which suggests that the treatment is not effective. Weight loss is often a concerning sign in patients with chronic pancreatitis and should be monitored closely. In an educational context, it is crucial for nursing students to understand the rationale behind assessing the effectiveness of specific treatments for gastrointestinal disorders like chronic pancreatitis. By recognizing the significance of key indicators such as stool characteristics in this case, students can develop critical thinking skills to evaluate patient responses to therapy and make informed clinical decisions to optimize patient outcomes.