Nursing Elites

1. A nurse teaches a preoperative client about the nasogastric tube that will be inserted in preparation for surgery. The nurse determines that the client understands when the tube will be removed in the postoperative period when the client states

• A. When my gastrointestinal system is healed enough.
• B. When I can tolerate food without vomiting.
• C. When my bowels begin to function again, and I begin to pass gas.
• D. When the doctor says so.

Correct answer: C

Rationale: Nasogastric tubes are discontinued when normal function returns to the gastrointestinal tract. The tube will be removed before gastrointestinal healing. Food would not be administered unless bowel function returns. Although the physician determines when the nasogastric tube will be removed, option 4 does not determine effectiveness of teaching.

2. You’re performing an abdominal assessment on Brent who is 52 y.o. In which order do you proceed?

• A. Observation, percussion, palpation, auscultation
• B. Observation, auscultation, percussion, palpation
• C. Percussion, palpation, auscultation, observation
• D. Palpation, percussion, observation, auscultation

Correct answer: B

Rationale: The correct order for performing an abdominal assessment is observation, auscultation, percussion, and palpation.

3. Which of the following conditions is most likely to directly cause peritonitis?

• A. Cholelithiasis
• B. Gastritis
• C. Perforated ulcer
• D. Incarcerated hernia

Correct answer: C

Rationale: A perforated ulcer is most likely to directly cause peritonitis due to the leakage of gastric contents into the peritoneal cavity.

4. Which of the following diagnostic tests may be performed to determine if a client has gastric cancer?

• A. Barium enema
• B. Colonoscopy
• C. Gastroscopy
• D. Serum chemistry levels

Correct answer: C

Rationale: A gastroscopy is performed to visualize the stomach lining and obtain biopsies to diagnose gastric cancer.

5. A nurse is reviewing the orders of a client admitted to the hospital with a diagnosis of acute pancreatitis. Select the interventions that the nurse would expect to be prescribed for the client.

• A. Small, frequent high-calorie feedings.
• B. Meperidine (Demerol) as prescribed for pain.
• C. Place the client in a side-lying position with the head elevated 45-degrees.
• D. Administer antacids and anticholinergics to suppress gastrointestinal secretions.

Correct answer: B

Rationale: The correct intervention for a client with acute pancreatitis is to prescribe pain medications such as meperidine to manage the abdominal pain, which is a prominent symptom of the condition. The other options are incorrect because: A) Clients with acute pancreatitis are normally placed on NPO (nothing by mouth) status to rest the pancreas, so small, frequent high-calorie feedings are not indicated. C) Placing the client in a side-lying position with the head elevated 45-degrees helps decrease tension on the abdomen and may ease pain, but it is not a standard intervention for acute pancreatitis. D) Administering antacids and anticholinergics to suppress gastrointestinal secretions is not a routine intervention for acute pancreatitis.

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