Nursing Elites

1. The nurse is caring for a client following a Billroth II procedure. On review of the post-operative orders, which of the following, if prescribed, would the nurse question and verify?

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

Correct answer: A

Rationale: Irrigating the nasogastric tube is typically not recommended after a Billroth II procedure unless specifically ordered by a physician due to the risk of disrupting the surgical site.

2. 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.

3. A client with viral hepatitis states, 'I am so yellow.' The nurse most appropriately would

• A. Assist the client in expressing feelings.
• B. Do most of the activities of daily living for the client.
• C. Provide information to the client only when the client requests it.
• D. Restrict visitors until the jaundice subsides.

Correct answer: A

Rationale: To assist the client in adapting to changes in appearance, the nurse must encourage participation in self-care to foster independence and self-esteem. The nurse should encourage the client to ask questions to clarify misconceptions, learn ways to prevent the spread of hepatitis to reduce fear, and make appropriate decisions. Restricting visitors will reinforce the client’s negative self-esteem.

4. Which of the following tests can be performed to diagnose a hiatal hernia?

• A. Colonoscopy
• B. Lower GI series
• C. Barium swallow
• D. Abdominal x-rays

Correct answer: C

Rationale: A barium swallow is a diagnostic test that can visualize the esophagus, stomach, and small intestine to diagnose a hiatal hernia.

5. Glenda has cholelithiasis (gallstones). You expect her to complain of:

• A. Pain in the right upper quadrant, radiating to the shoulder.
• B. Pain in the right lower quadrant, with rebound tenderness.
• C. Pain in the left upper quadrant, with shortness of breath.
• D. Pain in the left lower quadrant, with mild cramping.

Correct answer: A

Rationale: Patients with cholelithiasis often complain of pain in the right upper quadrant, radiating to the shoulder.

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