Nursing Elites

1. Which assessment information will be most important for the nurse to report to the healthcare provider about a patient with acute cholecystitis?

• A. The patient's urine is bright yellow
• B. The patient's stools are tan colored
• C. The patient has increased pain after eating
• D. The patient complains of chronic heartburn

Correct answer: B

Rationale: The correct answer is that the patient's stools are tan colored. Tan or grey stools indicate biliary obstruction, which requires rapid intervention to resolve in a patient with acute cholecystitis. This change in stool color is a critical sign that the healthcare provider needs to be informed about promptly. The other choices are less concerning and may be common symptoms in patients with acute cholecystitis, but tan-colored stools specifically indicate a potential serious complication that warrants immediate attention.

2. The infant has a diagnosis of bladder exstrophy. To protect the exposed bladder tissue, what intervention should the nurse plan?

• A. Cover the bladder with petroleum jelly gauze.
• B. Cover the bladder with a non-adhering plastic wrap.
• C. Apply sterile distilled water dressings over the bladder mucosa.
• D. Keep the bladder tissue dry by covering it with dry sterile gauze.

Correct answer: C

Rationale: Bladder exstrophy is a condition where the bladder is exposed and external to the body. To protect the exposed bladder tissue from drying out while allowing urine drainage, it is best to cover the bladder with a non-adhering plastic wrap. Using petroleum jelly gauze should be avoided as it can dry out, adhere to the mucosa, and damage delicate tissue upon removal. Applying sterile distilled water dressings can also dry out and cause damage when removed. Keeping the bladder tissue dry with sterile gauze is not ideal as maintaining a moist environment is important for tissue protection in this case.

3. A nurse admits a 3-week-old infant to the special care nursery with a diagnosis of bronchopulmonary dysplasia. As the nurse reviews the birth history, which data would be most consistent with this diagnosis?

• A. Gestational age assessment suggested growth retardation
• B. Meconium was cleared from the airway at delivery
• C. Phototherapy was used to treat Rh incompatibility
• D. The infant received mechanical ventilation for 2 weeks

Correct answer: D

Rationale: The correct answer is 'The infant received mechanical ventilation for 2 weeks.' Bronchopulmonary dysplasia is a condition primarily caused by therapies like positive-pressure ventilation used in the treatment of lung disease. This leads to lung damage and subsequent respiratory problems. Choices A, B, and C are not consistent with the diagnosis of bronchopulmonary dysplasia. Gestational age assessment suggesting growth retardation is more indicative of intrauterine growth restriction, clearing meconium from the airway at delivery is related to potential respiratory issues at birth, and phototherapy for Rh incompatibility is unrelated to bronchopulmonary dysplasia.

4. A client was recently diagnosed with diverticulosis. What types of foods should the nurse recommend for this client?

• A. Whole grain cereal
• B. Eggs
• C. Cottage cheese
• D. Fish

Correct answer: A

Rationale: Diverticulosis is a condition characterized by small protrusions in the intestinal tract. To manage diverticulosis, a high-fiber diet is recommended. Foods rich in fiber help prevent constipation and reduce the risk of inflammation in the intestines. Whole grain cereals are an excellent source of fiber and can aid in maintaining bowel regularity. Eggs, cottage cheese, and fish are not high-fiber foods and may not provide the necessary dietary support for a client with diverticulosis. While protein-rich foods like eggs and fish are beneficial for overall health, they are not the primary recommendation for managing diverticulosis.

5. The nurse completes discharge teaching for a patient who has had a lung transplant. The nurse evaluates that the teaching has been effective if the patient makes which statement?

• A. I will make an appointment to see the doctor every year.
• B. I will stop taking the prednisone if I experience a dry cough.
• C. I will not worry if I feel a little short of breath with exercise.
• D. I will call the health care provider right away if I develop a fever.

Correct answer: D

Rationale: The correct answer is, 'I will call the health care provider right away if I develop a fever.' It is crucial for patients who have undergone a lung transplant to be vigilant about any signs of infection or rejection. A low-grade fever can be an early indicator of such complications, requiring immediate medical attention. While annual follow-up visits are necessary, they are not sufficient for monitoring acute changes in health post-transplant. Stopping prednisone abruptly can lead to rejection and should only be done under healthcare provider guidance. Feeling short of breath with exercise should be reported as it can indicate potential issues. Recognizing and addressing symptoms promptly is key to successful post-transplant care, and in this case, calling the healthcare provider immediately for a fever is the most appropriate action.

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