Nursing Elites

1. A patient with Crohn’s disease is admitted after 4 days of diarrhea. Which of the following urine specific gravity values do you expect to find in this patient?

• A. 1.005
• B. 1.011
• C. 1.02
• D. 1.03

Correct answer: D

Rationale: A urine specific gravity of 1.030 indicates concentrated urine, which is expected in a patient with dehydration due to diarrhea from Crohn’s disease.

2. Before bowel surgery, Lee is to administer enemas until clear. During administration, he complains of intestinal cramps. What do you do next?

• A. Discontinue the procedure.
• B. Lower the height of the enema container.
• C. Complete the procedure as quickly as possible.
• D. Continue administration of the enema as ordered without making any adjustments.

Correct answer: B

Rationale: If a patient complains of intestinal cramps during an enema, lowering the height of the enema container can help reduce discomfort.

3. You’re discharging Nathaniel with hepatitis B. Which statement suggests understanding by the patient?

• A. Now I can never get hepatitis again.
• B. I can safely give blood after 3 months.
• C. I’ll never have a problem with my liver again, even if I drink alcohol.
• D. My family knows that if I get tired and start vomiting, I may be getting sick again.

Correct answer: D

Rationale: Understanding that family needs to be aware of symptoms that may indicate a recurrence of hepatitis B shows proper understanding by the patient.

4. Your goal is to minimize David’s risk of complications after a heriorrhaphy. You instruct the patient to:

• A. Avoid the use of pain medication.
• B. Cough and deep breathe Q2H.
• C. Splint the incision if he can’t avoid sneezing or coughing.
• D. Apply heat to scrotal swelling.

Correct answer: C

Rationale: Instruct the patient to splint the incision if he can't avoid sneezing or coughing to minimize the risk of complications after heriorrhaphy.

5. A nurse has been caring for a client with a Sengstaken-Blakemore tube. The physician arrives on the nursing unit and deflates the esophageal balloon. The nurse should monitor the client most closely for which of the following?

• A. Swelling of the abdomen
• B. Bloody diarrhea
• C. Vomiting blood
• D. An elevated temperature and arise in blood pressure

Correct answer: C

Rationale: A Sengstaken-Blakemore tube is inserted into a client with a diagnosis of cirrhosis and ruptured esophageal varices. The tube has an esophageal and a gastric balloon. The esophageal balloon exerts pressure on the bleeding. The pressure of the esophageal balloon is released at intervals to decrease the risk of trauma to esophageal tissues, including esophageal rupture or necrosis. When the balloon is deflated the client may begin to bleed again from the esophageal varices, noted by vomiting of blood.

Similar Questions