Nursing Elites

1. Brenda, a 36 y.o. patient is on your floor with acute pancreatitis. Treatment for her includes:

• A. Continuous peritoneal lavage.
• B. Regular diet with increased fat.
• C. Nutritional support with TPN.
• D. Insertion of a T tube to drain the pancreas.

Correct answer: C

Rationale: Treatment for acute pancreatitis includes nutritional support with TPN.

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. A client has been diagnosed with adenocarcinoma of the stomach and is scheduled to undergo a subtotal gastrectomy (Billroth II procedure). During pre-operative teaching, the nurse is reinforcing information about the procedure. Which of the following explanations is most accurate?

• A. The procedure will result in enlargement of the pyloric sphincter
• B. The procedure will result in anastomosis of the gastric stump to the jejunum
• C. The procedure will result in removal of the duodenum
• D. The procedure will result in repositioning of the vagus nerve

Correct answer: B

Rationale: The Billroth II procedure involves anastomosis of the gastric stump to the jejunum.

4. Lactulose (Chronulac) is prescribed for a client with a diagnosis of hepatic encephalopathy. The nurse would determine that this medication has had a therapeutic effect if which of the following is noted?

• A. Increased red blood cell count
• B. Decreased serum ammonia level
• C. Increased protein level
• D. Decreased white blood cell level

Correct answer: B

Rationale: Lactulose is prescribed for the client with hepatic encephalopathy to reduce bacterial breakdown of protein in the bowel. The medication creates an acidic environment in the bowel and causes the ammonia to leave the bloodstream and enter the colon. Ammonia then becomes trapped in the bowel. Lactulose also has a laxative effect that allows for the elimination of the ammonia.

5. You’re assessing the stoma of a patient with a healthy, well-healed colostomy. You expect the stoma to appear:

• A. Pale, pink and moist
• B. Red and moist
• C. Dark or purple colored
• D. Dry and black

Correct answer: B

Rationale: A healthy, well-healed colostomy stoma should appear red and moist.

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