Nursing Elites

1. A client has a percutaneous endoscopic gastrostomy tube inserted for tube feedings. Before starting a continuous feeding, the nurse should place the client in which position?

• A. Semi-Fowlers
• B. Supine
• C. Reverse Trendelenburg
• D. High Fowler’s

Correct answer: D

Rationale: Placing the client in a high Fowler’s position helps prevent aspiration and promotes proper digestion and feeding tube function.

2. You have to teach ostomy self care to a patient with a colostomy. You tell the patient to measure and cut the wafer:

• A. To the exact size of the stoma.
• B. About 1/16” larger than the stoma.
• C. About 1/8” larger than the stoma.
• D. About 1/4″ larger than the stoma.

Correct answer: C

Rationale: The wafer should be measured and cut about 1/8” larger than the stoma to ensure proper fit and prevent skin irritation.

3. A client with viral hepatitis states, 'I am so yellow.' The nurse most appropriately would

• A. Assist the client in expressing feelings.
• B. Do most of the activities of daily living for the client.
• C. Provide information to the client only when the client requests it.
• D. Restrict visitors until the jaundice subsides.

Correct answer: A

Rationale: To assist the client in adapting to changes in appearance, the nurse must encourage participation in self-care to foster independence and self-esteem. The nurse should encourage the client to ask questions to clarify misconceptions, learn ways to prevent the spread of hepatitis to reduce fear, and make appropriate decisions. Restricting visitors will reinforce the client’s negative self-esteem.

4. Jerod is experiencing an acute episode of ulcerative colitis. What is the priority for this patient?

• A. Replace lost fluid and sodium.
• B. Monitor for increased serum glucose levels from steroid therapy.
• C. Restrict dietary intake of foods high in potassium.
• D. Note any change in the color and consistency of stools.

Correct answer: A

Rationale: The correct answer is to replace lost fluid and sodium. During an acute episode of ulcerative colitis, the priority is to manage the patient's fluid and electrolyte balance. This is crucial due to the potential for dehydration and electrolyte imbalances resulting from diarrhea and inflammation in the colon. Monitoring serum glucose levels (Choice B) may be important for patients on steroid therapy, but in this scenario, fluid and electrolyte balance take precedence. Restricting dietary intake of foods high in potassium (Choice C) is not a priority in the acute phase of ulcerative colitis. While noting changes in stool color and consistency (Choice D) is important for assessing the patient's gastrointestinal status, it is not the priority when managing acute ulcerative colitis.

5. A client with liver dysfunction has low serum levels of thrombin. The nurse provides care, anticipating that this client is most at risk of

• A. Dehydration
• B. Malnutrition
• C. Bleeding
• D. Infection

Correct answer: C

Rationale: Thrombin is produced by the liver and is necessary for normal clotting. When a client with liver dysfunction has low serum levels of thrombin, they are at risk of bleeding due to impaired clotting mechanisms. Dehydration (choice A) is not directly related to low thrombin levels. Malnutrition (choice B) may impact overall health but is not the most immediate concern associated with low thrombin levels. Infection (choice D) is not directly related to the clotting function affected by low thrombin levels.

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