Nursing Elites

1. A nurse is providing instructions to a client who will collect a stool specimen for occult blood. The nurse instructs the client to avoid which of the following for 3 days before the collection of the stool specimen?

• A. Milk products
• B. Hard cheese
• C. Turnips
• D. Cottage cheese

Correct answer: C

Rationale: The correct answer is C: Turnips. The nurse would instruct the client to avoid red meat, poultry, fish, turnips, horseradish, and foods such as fruits and vegetables for 3 days before and during testing. These products may alter test results. Choices A, B, and D are incorrect because they are not specifically mentioned as items to avoid before collecting a stool specimen for occult blood.

2. When planning care for a client with ulcerative colitis who is experiencing symptoms, which client care activities can the nurse appropriately delegate to a unlicensed assistant?

• A. Assessing the client's bowel sounds
• B. Providing skin care following bowel movements
• C. Evaluating the client's response to antidiarrheal medications
• D. administration of pain medication every 4 hours

Correct answer: B

Rationale: Providing skin care following bowel movements, maintaining intake and output records, and obtaining the client's weight can be delegated to a unlicensed assistant.

3. The nurse is performing an assessment on a client with acute pancreatitis who was admitted to the hospital. Which of the following assessment questions most specifically would elicit information regarding the pain that is associated with acute pancreatitis?

• A. Does the pain in your abdomen radiate to your groin.
• B. Does the pain in your stomach radiate to the back?
• C. Does the pain in your stomach radiate to your lower middle abdomen?
• D. Does the pain in your lower abdomen radiate to the hip?

Correct answer: B

Rationale: The pain that is associated with acute pancreatitis is often severe and is located in the epigastric region and radiates to the back. Options 1, 3, and 4 are incorrect because they are not specific for the pain experienced by the client with pancreatitis.

4. Arthur has a family history of colon cancer and is scheduled to have a sigmoidoscopy. He is crying as he tells you, “I know that I have colon cancer, too.” Which response is most therapeutic?

• A. I know just how you feel.
• B. You seem upset.
• C. Oh, don’t worry about it, everything will be just fine.
• D. Why do you think you have cancer?

Correct answer: B

Rationale: Acknowledging the patient's emotions with 'You seem upset' is the most therapeutic response.

5. A nurse is developing a plan of care for a client who will be returning to a nursing unit following a percutaneous transhephatic cholangiogram. The nurse includes which intervention in the postprocedure plan of care?

• A. Place a sandbag over the insertion site.
• B. Allow the client bathroom privileges only.
• C. Encourage fluid intake.
• D. Allow the client to sit in a chair for meals.

Correct answer: A

Rationale: Following this procedure, the nurse monitors the client’s vital signs closely for indications of hemorrhage and observes the needle insertion site for bleeding and bile leakage. A sandbag is placed over the insertion site to prevent bleeding. The client is maintained on bedrest, and oral intake is avoided in the immediate postprocedure period in case surgery is necessary to control hemorrhage of bile extravasation.

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