Nursing Elites

1. 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.

2. The nurse is monitoring a client for the early signs and symptoms for dumping syndrome. Which symptom indicates this occurrence?

• A. Abdominal cramping and pain
• B. Bradycardia and indigestion
• C. Sweating and pallor
• D. Double vision and chest pain

Correct answer: C

Rationale: Early manifestations of dumping syndrome occur 5 to 30 minutes after eating. Symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down.

3. 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.

4. A nurse is preparing to remove a nasogastric tube from a client. The nurse would instruct the client to do which of the following just before the nurse removes the tube?

• A. To perform Valsalva’s maneuver
• B. To take hold and hold a deep breath
• C. To exhale
• D. To inhale and exhale quickly

Correct answer: B

Rationale: When the nurse removes a nasogastric tube, the client is instructed to take and hold a deep breath. This will be obstructed temporarily during the tube removal. This allows for easy withdrawal through the esophagus into the nose. The nurse removes the tube with one smooth, continuous pull.

5. A client with gastric cancer may exhibit which of the following symptoms?

• A. Abdominal cramping
• B. Constant hunger
• C. Feeling of fullness
• D. Weight gain

Correct answer: C

Rationale: Clients with gastric cancer may experience a feeling of fullness due to the presence of the tumor.

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