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. Which of the following dietary measures would be useful in preventing esophageal reflux?

• A. Eating small, frequent meals
• B. Increasing fluid intake
• C. Avoiding air swallowing with meals
• D. Adding a bedtime snack to the dietary plan

Correct answer: A

Rationale: Eating small, frequent meals helps prevent esophageal reflux.

3. The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis. The client is scheduled for surgery for 2 hours. The client begins to complain of increases abdominal pain and begins to vomit. On assessment the nurse notes that the abdomen distended and bowel sounds are diminished. Which of the following is the most appropriate nursing intervention?

• A. Administer the prescribed pain medication.
• B. Notify the physician.
• C. Call and ask the operating room team to perform the surgery as soon as possible.
• D. Reposition the client and apply a heating pad on warm setting to the client’s abdomen.

Correct answer: B

Rationale: Based on the signs and symptoms presented in the question, the nurse should suspect peritonitis and should notify the physician. Administering pain medication is not an appropriate intervention. Heat should never be applied to the abdomen of a client with suspected appendicitis. Scheduling surgical time is not within the scope of nursing practice, although the physician probably would perform the surgery earlier than the prescheduled time.

4. You’re caring for Jane, a 57 y.o. patient with liver cirrhosis who develops ascites and requires paracentesis. Before her paracentesis, you instruct her to:

• A. Empty her bladder.
• B. Lie supine in bed.
• C. Remain NPO for 4 hours.
• D. Clean her bowels with an enema.

Correct answer: A

Rationale: Before paracentesis, instruct the patient to empty her bladder to avoid bladder injury during the procedure.

5. You’re caring for a patient with a sigmoid colostomy. The stool from this colostomy is:

• A. Formed
• B. Semisolid
• C. Semiliquid
• D. Watery

Correct answer: A

Rationale: The stool from a sigmoid colostomy is typically formed.

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