Nursing Elites

1. A client with peptic ulcer disease tells the nurse that he has black stools, which he has not reported to his physician. Based on this information, which nursing diagnosis would be appropriate for this client?

• A. Ineffective coping related to fear of diagnosis of chronic illness
• B. Deficient knowledge related to unfamiliarity with significant signs and symptoms
• C. Constipation related to decreased gastric motility
• D. Imbalanced nutrition: Less than body requirements due to gastric bleeding

Correct answer: B

Rationale: Deficient knowledge related to unfamiliarity with significant signs and symptoms is appropriate because the client did not report the black stools, which can be a sign of bleeding.

2. After a subtotal gastrectomy, care of the client’s nasogastric tube and drainage system should include which of the following nursing interventions?

• A. Irrigate the tube with 30 ml of sterile water every hour, if needed.
• B. Reposition the tube if it is not draining well
• C. Monitor the client for N/V, and abdominal distention
• D. Turn the machine to high suction of the drainage is sluggish on low suction.

Correct answer: C

Rationale: Monitoring the client for nausea, vomiting, and abdominal distention is crucial for ensuring proper functioning of the nasogastric tube and drainage system.

3. Elmer is scheduled for a proctoscopy and has an I.V. The doctor wrote an order for 5mg of I.V. diazepam(Valium). Which order is correct regarding diazepam?

• A. Give diazepam in the I.V. port closest to the vein.
• B. Mix diazepam with 50 ml of dextrose 5% in water and give over 15 minutes.
• C. Give diazepam rapidly I.V. to prevent the bloodstream from diluting the drug mixture.
• D. Question the order because I.V. administration of diazepam is contraindicated.

Correct answer: A

Rationale: The correct method for administering I.V. diazepam is to give it in the I.V. port closest to the vein.

4. During an abdominal assessment, a nurse finds pulsation between the umbilicus and pubis on a client. What finding should be reported to the physician?

• A. Concave, midline umbilicus
• B. Pulsation between the umbilicus and pubis
• C. Bowel sound frequency of 15 sounds per minute
• D. Absence of a bruit

Correct answer: B

Rationale: The presence of pulsation between the umbilicus and pubis could indicate an abdominal aortic aneurysm, which is a serious condition and should be reported to the physician promptly. A concave, midline umbilicus is a normal finding. Bowel sound frequency can vary widely and is not a cause for concern at 15 sounds per minute. Absence of a bruit is a normal finding in an abdominal assessment and does not require reporting.

5. A client is to take one daily dose of ranitidine (Zantac) at home to treat her peptic ulcer. The nurse knows that the client understands proper drug administration of ranitidine when she says that she will take the drug at which of the following times?

• A. Before meals
• B. With meals
• C. At bedtime
• D. When pain occurs

Correct answer: C

Rationale: Ranitidine (Zantac) is best taken at bedtime to reduce stomach acid production overnight.

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