Nursing Elites

1. 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.

2. Cholestyramine resin (Questran Light) is prescribed for the client with an elevated serum cholesterol level. The nurse would instruct the client to take the medication

• A. After meals.
• B. Mixed with fruit juice.
• C. Via rectal suppository.
• D. At least 3 hours before meals.

Correct answer: B

Rationale: Cholestyramine resin binds with bile salts in the intestines to form a compound that is excreted in the feces. The client should be instructed to mix the medication with 3 to 6 oz of water, milk, fruit juice, or soup. The medication should be administered before meals. The medication is not administered via rectal suppository.

3. If a gastric acid perforates, which of the following actions should not be included in the immediate management of the client?

• A. Blood replacement
• B. Antacid administration
• C. Nasogastric tube suction
• D. Fluid and electrolyte replacement

Correct answer: B

Rationale: Antacid administration should not be included in the immediate management of a gastric perforation.

4. The client with a colostomy has an order for irrigation of the colostomy. The nurse uses which solution for the irrigation?

• A. Distilled water
• B. Tap water
• C. Sterile water
• D. Lactated Ringer’s

Correct answer: B

Rationale: The correct solution to use for the irrigation of a colostomy is warm tap water or saline solution. If tap water is not suitable for drinking, bottled water can be used. Distilled water, sterile water, and Lactated Ringer’s are not appropriate solutions for colostomy irrigation. Distilled water lacks essential minerals, sterile water may not provide adequate cleaning, and Lactated Ringer’s is not indicated for this procedure.

5. Your patient has a retractable gastric peptic ulcer and has had a gastric vagotomy. Which factor increases as a result of vagotomy?

• A. Peristalsis.
• B. Gastric acidity.
• C. Gastric motility.
• D. Gastric pH.

Correct answer: D

Rationale: After a gastric vagotomy, the gastric pH increases as a result of reduced acid secretion.

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