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. When a client has peptic ulcer disease, the nurse would expect a priority intervention to be:

• A. Assisting in inserting a Miller-Abbott tube
• B. Assisting in inserting an arterial pressure line
• C. Inserting a nasogastric tube
• D. Inserting an I.V.

Correct answer: C

Rationale: Inserting a nasogastric tube is a priority intervention for a client with peptic ulcer disease to decompress the stomach.

3. The nurse instructs the nursing assistant on how to provide oral hygiene for a client who cannot perform this task for himself. Which of the following techniques should the nurse tell the assistant to incorporate into the client’s daily care?

• A. Assess the oral cavity each time mouth care is given and record observations
• B. Use a soft toothbrush to brush the client’s teeth after each meal
• C. Swab the client’s tongue, gums, and lips with a soft foam applicator every 2 hours.
• D. Rinse the client’s mouth with mouthwash several times a day.

Correct answer: C

Rationale: Swabbing the client’s tongue, gums, and lips with a soft foam applicator every 2 hours helps maintain oral hygiene for a client who cannot perform this task.

4. To prevent gastroesophageal reflux in a client with hiatal hernia, the nurse should provide which discharge instructions?

• A. Lie down after meals to promote digestion.
• B. Avoid coffee and alcoholic beverages.
• C. Take antacids before meals.
• D. Limit fluids with meals.

Correct answer: B

Rationale: To prevent reflux of stomach acid into the esophagus, the nurse should advise the client to avoid foods and beverages that tend to increase stomach acid, such as coffee and alcohol. The nurse also should teach the client to avoid lying down after meals, which can aggravate reflux, and to take antacids after eating. The client doesn't need to limit fluids with meals as long as the fluids aren't gastric irritants.

5. You’re caring for Carin who has just had ileostomy surgery. During the first 24 hours post-op, how much drainage can you expect from the ileostomy?

• A. 100 ml
• B. 500 ml
• C. 1500 ml
• D. 5000 ml

Correct answer: C

Rationale: During the first 24 hours post-op, you can expect about 1500 ml of drainage from the ileostomy.

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