Nursing Elites

1. The nurse is caring for a client with cirrhosis. Which manifestations indicate deficient vitamin K absorption caused by this liver disease?

• A. Dyspnea and fatigue
• B. Ascites and orthopnea
• C. Purpura and petechiae
• D. Gynecomastia and testicular atrophy

Correct answer: C

Rationale: A liver disorder, such as cirrhosis, can disrupt the liver's normal use of vitamin K to produce prothrombin (a clotting factor). Because of this, the nurse should monitor the client for signs of bleeding, including purpura and petechiae. Dyspnea and fatigue suggest anemia. Ascites and orthopnea are unrelated to vitamin K absorption. Gynecomastia and testicular atrophy result from decreased estrogen metabolism by the diseased liver.

2. A client’s ulcerative colitis symptoms have been present for longer than 1 week. The nurse recognizes that the client should be assessed carefully for signs of which of the following complications?

• A. Heart failure
• B. DVT
• C. Hypokalemia
• D. Hypocalcemia

Correct answer: C

Rationale: The client should be assessed carefully for signs of hypokalemia, a common complication of prolonged ulcerative colitis symptoms.

3. The student nurse is preparing a teaching care plan to help improve nutrition in a patient with achalasia. You include which of the following:

• A. Swallow foods while leaning forward.
• B. Omit fluids at mealtimes.
• C. Eat meals sitting upright.
• D. Avoid soft and semisoft foods.

Correct answer: C

Rationale: Eating meals while sitting upright helps improve swallowing and prevent complications in patients with achalasia.

4. Which of the following symptoms is common with a hiatal hernia?

• A. Left arm pain
• B. Lower back pain
• C. Esophageal reflux
• D. Abdominal cramping

Correct answer: C

Rationale: Esophageal reflux is a common symptom of a hiatal hernia because the hernia can cause stomach acid to move back up into the esophagus.

5. The client has orders for a nasogastric (NG) tube insertion. During the procedure, instructions that will assist in the insertion would be:

• A. Instruct the client to tilt his head back for insertion in the nostril, then flex his neck for the final insertion
• B. After insertion into the nostril, instruct the client to extend his neck
• C. Introduce the tube with the client’s head tilted back, then instruct him to keep his head upright for final insertion
• D. Instruct the client to hold his chin down, then back for insertion of the tube

Correct answer: A

Rationale: Instructing the client to tilt his head back for insertion in the nostril, then flex his neck for the final insertion helps facilitate the NG tube insertion.

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