Nursing Elites

1. The client being treated for esophageal varices has a Sengstaken-Blakemore tube inserted to control the bleeding. The most important assessment is for the nurse to:

• A. Check that the hemostat is on the bedside
• B. Monitor IV fluids for the shift
• C. Regularly assess respiratory status
• D. Check that the balloon is deflated on a regular basis

Correct answer: C

Rationale: Regularly assessing respiratory status is crucial when a Sengstaken-Blakemore tube is inserted to control bleeding in esophageal varices.

2. Which of the following diagnostic tests should be performed annually over age 50 to screen for colon cancer?

• A. Abdominal CT scan
• B. Abdominal x-ray
• C. Colonoscopy
• D. Fecal occult blood test

Correct answer: D

Rationale: A fecal occult blood test should be performed annually for individuals over age 50 to screen for colon cancer.

3. A client with viral hepatitis is discussing with the nurse the need to avoid alcohol and states, 'I’m not sure I can avoid alcohol.' The most appropriate response is

• A. Everything will be alright.
• B. I think you should talk more with the doctor about this.
• C. I don’t believe that.
• D. I’m not sure that I don’t understand. Would you please explain?

Correct answer: D

Rationale: The most appropriate response in this situation is to seek clarification from the client by saying, 'I’m not sure that I don’t understand. Would you please explain?' This response shows empathy and a willingness to listen, encouraging the client to elaborate on their concerns. False reassurance (Choice A) is not helpful as it dismisses the client's feelings. Suggesting to talk more with the doctor (Choice B) may deflect from addressing the client's immediate concerns. Expressing disbelief (Choice C) can create a barrier to open communication, making the client feel unsupported.

4. Which nursing measure would be most effective in helping the client cough and deep breathe after a cholecystectomy?

• A. Having the client take rapid, shallow breaths to decrease pain.
• B. Having the client lay on the left side while coughing and deep breathing.
• C. Teaching the client to use a folded blanket or pillow to splint the incision.
• D. Withholding pain medication so the client can be alert enough to follow the nurse's instructions.

Correct answer: C

Rationale: After a cholecystectomy, teaching the client to use a folded blanket or pillow to splint the incision will be most effective in helping the client cough and deep breathe. This technique provides support and reduces pain during coughing and deep breathing, promoting better lung expansion. Having the client take rapid, shallow breaths would not be effective in decreasing pain; instead, deep breathing is encouraged to prevent complications like atelectasis. Lying on the left side would limit lung expansion; therefore, the client should be positioned in semi-Fowler's or Fowler's position to maximize lung expansion. Withholding pain medication can lead to discomfort and reluctance to cough and deep breathe, hindering recovery.

5. A client who has had gastrectomy is not producing sufficient intrinsic factor. The nurse interprets that the client has lost the ability to absorb cyanocobalamin (vitamin B12) in the

• A. Stomach.
• B. Small intestine.
• C. Large intestine.
• D. Colon.

Correct answer: B

Rationale: Intrinsic factor is produced in the stomach but is used to aid in the absorption of vitamin B12 in the small intestine. Vitamin B12 is not absorbed in the large intestine (options 3 and 4).

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