Nursing Elites

1. A patient has an acute upper GI hemorrhage. Your interventions include:

• A. Treating hypovolemia.
• B. Treating hypervolemia.
• C. Controlling the bleeding source.
• D. Treating shock and diagnosing the bleeding source.

Correct answer: D

Rationale: For a patient with an acute upper GI hemorrhage, your interventions include treating shock and diagnosing the bleeding source.

2. Hepatic encephalopathy develops when the blood level of which substance increases?

• A. Ammonia
• B. Amylase
• C. Calcium
• D. Potassium

Correct answer: A

Rationale: Hepatic encephalopathy develops when the blood level of ammonia increases.

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. Your patient with peritonitis is NPO and complaining of thirst. What is your priority?

• A. Increase the I.V. infusion rate.
• B. Use diversion activities.
• C. Provide frequent mouth care.
• D. Give ice chips every 15 minutes.

Correct answer: C

Rationale: The correct answer is C: Provide frequent mouth care. In a patient with peritonitis who is NPO and thirsty, the priority is to maintain oral hygiene and provide comfort by moistening the mouth with frequent mouth care. This helps alleviate the sensation of thirst and maintains oral health. Increasing the IV infusion rate (choice A) may not address the patient's discomfort directly related to thirst. Using diversion activities (choice B) is not as critical as addressing the patient's immediate need for oral care. Giving ice chips every 15 minutes (choice D) is not recommended for a patient with peritonitis who is NPO, as it can lead to complications or worsen the condition.

5. A client who has ulcerative colitis has persistent diarrhea. He is thin and has lost 12 pounds since the exacerbation of his ulcerative colitis. The nurse should anticipate that the physician will order which of the following treatment approaches to help the client meet his nutritional needs?

• A. Initiate continuous enteral feedings
• B. Encourage a high protein, high-calorie diet
• C. Implement total parenteral nutrition
• D. Provide six small meals a day.

Correct answer: C

Rationale: Implementing total parenteral nutrition helps meet the nutritional needs of a client with persistent diarrhea and significant weight loss due to ulcerative colitis.

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