Nursing Elites

1. 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.

2. Kevin has a history of peptic ulcer disease and vomits coffee-ground emesis. What does this indicate?

• A. He has fresh, active upper GI bleeding.
• B. He needs immediate saline gastric lavage.
• C. His gastric bleeding occurred 2 hours earlier.
• D. He needs a transfusion of packed RBC’s.

Correct answer: C

Rationale: Coffee-ground emesis indicates that the gastric bleeding occurred 2 hours earlier.

3. After an abdominal resection for colon cancer, Madeline returns to her room with a Jackson-Pratt drain in place. The purpose of the drain is to:

• A. Irrigate the incision with a saline solution.
• B. Prevent bacterial infection of the incision.
• C. Measure the amount of fluid lost after surgery.
• D. Prevent accumulation of drainage in the wound.

Correct answer: D

Rationale: The purpose of the Jackson-Pratt drain is to prevent the accumulation of drainage in the wound after an abdominal resection.

4. Janice is waiting for discharge instructions after her herniorrhaphy. Which of the following instructions do you include?

• A. Eat a low-fiber diet.
• B. Resume heavy lifting in 2 weeks.
• C. Lose weight, if obese.
• D. Resume sexual activity once discomfort is gone.

Correct answer: C

Rationale: Advise the patient to lose weight if obese to reduce the risk of complications after herniorrhaphy.

5. A client is suspected of having hepatitis. Which diagnostic test results will assist in confirming this diagnosis?

• A. Decreased erythrocyte sedimentation rate
• B. Elevated serum bilirubin
• C. Elevated hemoglobin
• D. Elevated blood urea nitrogen

Correct answer: B

Rationale: Laboratory indicators of hepatitis include elevated liver enzyme levels, elevated serum bilirubin levels, elevated erythrocyte sedimentation rates, and leucopenia. An elevated blood urea nitrogen may indicate renal dysfunction. A hemoglobin level is unrelated to this diagnosis.

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