Nursing Elites

1. The client has been admitted with a diagnosis of acute pancreatitis. The nurse would assess this client for pain that is:

• A. Severe and unrelenting, located in the epigastric area and radiating to the back.
• B. Severe and unrelenting, located in the left lower quadrant and radiating to the groin.
• C. Burning and aching, located in the epigastric area and radiating to the umbilicus.
• D. Burning and aching, located in the left lower quadrant and radiating to the hip.

Correct answer: A

Rationale: Acute pancreatitis typically presents with severe, unrelenting pain in the epigastric area that radiates to the back. This pain is due to inflammation and autodigestion of the pancreas.

2. 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.

3. A home care nurse is visiting a client with a diagnosis of pernicious anemia that developed as a result of gastric surgery. The nurse instructs the client that because the stomach lining produces a decreased amount of intrinsic factor in this disorder, the client will need

• A. Vitamin B12 injections.
• B. Vitamin B6 injections.
• C. An antibiotic.
• D. An antacid.

Correct answer: A

Rationale: A lack of the intrinsic factor needed to absorb vitamin B12 occurs in pernicious anemia. Vitamin B12 is needed for the maturation of red blood cells. Vitamin B6 is not necessarily needed for pernicious anemia and can be taken orally. An antibiotic and antacids may be prescribed for certain types of gastric ulcers.

4. The nurse is providing discharge instructions to a client following gastrectomy. Which measure will the nurse instruct the client to follow to assist in preventing dumping syndrome?

• A. Eat high-carbohydrate foods
• B. Limit the fluids taken with meals
• C. Ambulate following a meal
• D. Sit in a high-Fowlers position during meals

Correct answer: B

Rationale: To prevent dumping syndrome after a gastrectomy, it is recommended to limit fluids taken with meals to slow down gastric emptying and reduce the symptoms.

5. 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.

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