Nursing Elites

1. A nurse is inserting a nasogastric tube in an adult client. During the procedure, the client begins to cough and has difficulty breathing. Which of the following is the most appropriate nursing action?

• A. Remove the tube and reinsert when the respiratory distress subsides.
• B. Pull back on the tube and wait until the respiratory distress subsides.
• C. Quickly insert the tube.
• D. Notify the physician immediately.

Correct answer: B

Rationale: During the insertion of a nasogastric tube, if the client experiences difficulty breathing or any respiratory distress, withdraw the tube slightly, stop the tube advancement, and wait until the distress subsides. Options 1 and 4 are unnecessary. Quickly inserting the tube is not an appropriate action because, in this situation, it may be likely that the tube has entered the bronchus.

2. Which of the following associated disorders may a client with ulcerative colitis exhibit?

• A. Gallstones
• B. Hydronephrosis
• C. Nephrolithiasis
• D. Toxic megacolon

Correct answer: D

Rationale: Toxic megacolon is a severe complication that may be exhibited by a client with ulcerative colitis.

3. Which of the following symptoms is common with a hiatal hernia?

• A. Left arm pain
• B. Lower back pain
• C. Esophageal reflux
• D. Abdominal cramping

Correct answer: C

Rationale: Esophageal reflux is a common symptom of a hiatal hernia because the hernia can cause stomach acid to move back up into the esophagus.

4. A Penrose drain is in place on the first postoperative day following a cholecystectomy. Serosanguineous drainage is noted on the dressing covering the drain. Which nursing intervention is most appropriate?

• A. Notify the physician.
• B. Change the dressing.
• C. Circle the amount on the dressing with a pen.
• D. Continue to monitor the drainage.

Correct answer: B

Rationale: Serosanguineous drainage with a small amount of bile is expected from the Penrose drain for the first 24 hours. Drainage then decreases, and the drain is removed usually within 48 hours. The nurse does not need to notify the physician. A sterile dressing covers the site and should be changed to prevent infection and skin excoriation.

5. A client with a peptic ulcer reports epigastric pain that frequently awakens her at night, a feeling of fullness in the abdomen, and a feeling of anxiety about her health. Based on this information, which nursing diagnosis would be most appropriate?

• A. Imbalanced Nutrition: Less than Body Requirements related to anorexia.
• B. Disturbed Sleep Pattern related to epigastric pain
• C. Ineffective Coping related to exacerbation of duodenal ulcer
• D. Activity Intolerance related to abdominal pain

Correct answer: B

Rationale: Disturbed Sleep Pattern related to epigastric pain is appropriate because the client reports pain that frequently awakens her at night.

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