Nursing Elites

1. The hospitalized client with GERD is complaining of chest discomfort that feels like heartburn following a meal. After administering an ordered antacid, the nurse encourages the client to lie in which of the following positions?

• A. Supine with the head of the bed flat
• B. On the stomach with the head flat
• C. On the left side with the head of the bed elevated 30 degrees
• D. On the right side with the head of the bed elevated 30 degrees.

Correct answer: C

Rationale: Lying on the left side with the head of the bed elevated 30 degrees helps prevent reflux by keeping stomach contents from moving up into the esophagus.

2. The nurse is caring for a client following a Billroth II procedure. On review of the postoperative orders, which of the following if prescribed, should the nurse question and verify?

• A. Irrigating the nasogastric tube
• B. Coughing and deep breathing exercises
• C. Leg exercises
• D. Early ambulation

Correct answer: A

Rationale: In a Billroth II procedure the proximal remnant of the stomach is anastomosed to the proximal jejunum. Patency of the nasogastric tube is critical for preventing the retention of gastric secretions. The nurse should never irrigate or reposition the gastric tube after gastric surgery, unless specifically ordered by the physician. In this situation the nurse should clarify the order. Coughing and deep breathing exercises, leg exercises, and early ambulation are appropriate postoperative interventions.

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. Sitty, a 66 y.o. patient underwent a colostomy for ruptured diverticulum. She did well during the surgery and returned to your med-surg floor in stable condition. You assess her colostomy 2 days after surgery. Which finding do you report to the doctor?

• A. Blanched stoma
• B. Edematous stoma
• C. Reddish-pink stoma
• D. Brownish-black stoma

Correct answer: A

Rationale: A blanched stoma 2 days after colostomy surgery should be reported to the doctor as it may indicate compromised blood flow.

5. A nurse is caring for a client diagnose with pancreatitis. The nurse anticipates that the client would not experience an elevation of which of the following enzymes?

• A. Lipase
• B. Lactase
• C. Amylase
• D. Trypsin

Correct answer: B

Rationale: Lactase is produced in the small intestine and aids in splitting neutral fats into glycerol and fatty acids. Lipase, amylase, and trypsin are produced in the pancreas and aid in the digestion of fats, starches, and proteins, respectively.

Similar Questions