Nursing Elites

1. A client is scheduled for oral cholecystography. Which one of the following actions would the nurse plan to implement before the test?

• A. Have the client drink 1000 mL of water.
• B. Ask the client about possible allergies to iodine or shellfish.
• C. Administer an intravenous contrast agent the evening before the test.
• D. Administer tap-water enemas until clear.

Correct answer: B

Rationale: Iodine compounds used as radiographic contrast agents, such as iopanoic acid (Telepaque), should not be administered to the client with iodine and seafood allergies because anaphylaxis may occur.

2. A nurse is developing a teaching plan for the client with viral hepatitis. The nurse plans to tell the client which of the following in the teaching session?

• A. Activity should be limited to prevent fatigue
• B. The diet should be low in calories
• C. Meals should be large to conserve energy
• D. Alcohol intake should be limited to 2 oz. per day.

Correct answer: A

Rationale: The client with viral hepatitis should limit activity to avoid fatigue during the recuperation period. The diet should be optimal in calories, proteins, and carbohydrates. The client should take in several small meals per day. Alcohol is strictly forbidden.

3. Which of the following types of diets is implicated in the development of diverticulosis?

• A. Low-fiber diet
• B. High-fiber diet
• C. High-protein diet
• D. Low-carbohydrate diet

Correct answer: A

Rationale: A low-fiber diet is implicated in the development of diverticulosis because it leads to harder stools and increased pressure in the colon. The lack of fiber results in decreased bulk and slower transit time, predisposing individuals to constipation and the formation of diverticula. High-fiber diets, on the other hand, promote regular bowel movements and help prevent diverticular disease. High-protein and low-carbohydrate diets do not have a direct association with diverticulosis.

4. A nurse is performing an assessment on a client with a suspected diagnosis of acute pancreatitis. The nurse assesses the client, knowing that which of the following is a hallmark sign of this disorder?

• A. Severe abdominal pain relieved by vomiting
• B. Severe abdominal pain that is unrelieved by vomiting
• C. Hypothermia
• D. Epigastric pain radiating to the neck area

Correct answer: B

Rationale: A hallmark sign of acute pancreatitis is severe abdominal pain that is not relieved by vomiting. Nausea and vomiting are common presenting symptoms, with vomitus typically consisting of gastric and duodenal contents. Hypothermia is not a hallmark sign of acute pancreatitis. Fever, typically less than 38 degrees centigrade, is more common. Epigastric pain radiating to the neck area is not a characteristic sign of acute pancreatitis. Therefore, choice B is the correct answer.

5. A nurse is developing a plan of care for a client who will be returning to a nursing unit following a percutaneous transhephatic cholangiogram. The nurse includes which intervention in the postprocedure plan of care?

• A. Place a sandbag over the insertion site.
• B. Allow the client bathroom privileges only.
• C. Encourage fluid intake.
• D. Allow the client to sit in a chair for meals.

Correct answer: A

Rationale: Following this procedure, the nurse monitors the client’s vital signs closely for indications of hemorrhage and observes the needle insertion site for bleeding and bile leakage. A sandbag is placed over the insertion site to prevent bleeding. The client is maintained on bedrest, and oral intake is avoided in the immediate postprocedure period in case surgery is necessary to control hemorrhage of bile extravasation.

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