Nursing Elites

1. During the assessment of a client’s mouth, the nurse notes the absence of saliva. The client is also complaining of pain near the area of the ear. The client has been NPO for several days because of the insertion of an NG tube. Based on these findings, the nurse suspects that the client is developing which of the following mouth conditions?

• A. Stomatitis
• B. Oral candidiasis
• C. Parotitis
• D. Gingivitis

Correct answer: C

Rationale: The correct answer is C, Parotitis. Parotitis, inflammation of the parotid glands, can occur due to the absence of saliva and dehydration, often associated with being NPO and having an NG tube. Stomatitis (choice A) is inflammation of the oral mucosa, not specifically related to absent saliva. Oral candidiasis (choice B) is a fungal infection that can occur in the mouth, not directly related to the absence of saliva. Gingivitis (choice D) is inflammation of the gums and is not typically associated with the absence of saliva and dehydration.

2. After a right hemicolectomy for treatment of colon cancer, a 57-year old client is reluctant to turn while on bed rest. Which action by the nurse would be appropriate?

• A. Asking a co-worker to help turn the client
• B. Explaining to the client why turning is important.
• C. Allowing the client to turn when he’s ready to do so
• D. Telling the client that the physician’s order states he must turn every 2 hours

Correct answer: B

Rationale: Educating the client about the importance of turning can encourage compliance and promote understanding of the necessity to prevent complications such as pressure ulcers and pneumonia.

3. In a client with diarrhea, which outcome indicates that fluid resuscitation is successful?

• A. The client passes formed stools at regular intervals
• B. The client reports a decrease in stool frequency and liquidity
• C. The client exhibits firm skin turgor
• D. The client no longer experiences perianal burning

Correct answer: C

Rationale: Firm skin turgor indicates adequate hydration, which is a key goal of fluid resuscitation. Formed stools, decreased stool frequency, and relief from perianal burning are important but do not directly indicate successful fluid resuscitation.

4. A nurse is caring for a client who has a new diagnosis of Crohn's disease. Which of the following findings should the nurse expect?

• A. Bloody diarrhea
• B. Fatty stools
• C. Weight gain
• D. High fever

Correct answer: B

Rationale: Clients with Crohn's disease often experience fatty stools (steatorrhea) due to malabsorption of fats. This occurs because the inflammation caused by Crohn's disease can affect the small intestine, impairing the body's ability to absorb nutrients. Bloody diarrhea is more commonly associated with ulcerative colitis. Weight gain is not a typical symptom of Crohn's disease; instead, weight loss is more common due to malabsorption and decreased appetite. High fever can occur during acute flare-ups but is not a primary finding of Crohn's disease.

5. You’re patient, post-op drainage of a pelvic abscess secondary to diverticulitis, begins to cough violently after drinking water. His wound has ruptured and a small segment of the bowel is protruding. What’s your priority?

• A. Ask the patient what happened, call the doctor, and cover the area with a water-soaked bedsheet.
• B. Obtain vital signs, call the doctor, and obtain emergency orders.
• C. Have a CAN hold the wound together while you obtain vital signs, call the doctor and flex the patient’s knees.
• D. Have the doctor called while you remain with the patient, flex the patient’s knees, and cover the wound with sterile towels soaked in sterile saline solution.

Correct answer: D

Rationale: For a patient with a ruptured wound and protruding bowel, call the doctor while remaining with the patient, flex the patient’s knees, and cover the wound with sterile towels soaked in sterile saline solution.

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