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. Gail is scheduled for a cholecystectomy. After completion of preoperative teaching, Gail states,”If I lie still and avoid turning after the operation, I’ll avoid pain. Do you think this is a good idea?” What is the best response?

• A. You’ll need to turn from side to side every 2 hours.
• B. It’s always a good idea to rest quietly after surgery.
• C. The doctor will probably order you to lie flat for 24 hours.
• D. Why don’t you decide about activity after you return from the recovery room?

Correct answer: A

Rationale: The best response to Gail is to inform her that she will need to turn from side to side every 2 hours to prevent complications.

3. Which of the following diets is most commonly associated with colon cancer?

• A. Low-fiber, high fat
• B. Low-fat, high-fiber
• C. Low-protein, high-carbohydrate
• D. Low carbohydrate, high protein

Correct answer: A

Rationale: A low-fiber, high-fat diet is most commonly associated with an increased risk of colon cancer.

4. The nurse is caring for a hospitalized client with a diagnosis of ulcerative colitis. Which finding, if noted on assessment of the client, would the nurse report to the physician?

• A. Bloody diarrhea
• B. Hypotension
• C. A hemoglobin of 12 mg/dL
• D. Rebound tenderness

Correct answer: D

Rationale: Rebound tenderness is a sign of peritonitis, a serious complication that needs to be reported to the physician immediately.

5. Your goal is to minimize David’s risk of complications after a heriorrhaphy. You instruct the patient to:

• A. Avoid the use of pain medication.
• B. Cough and deep breathe Q2H.
• C. Splint the incision if he can’t avoid sneezing or coughing.
• D. Apply heat to scrotal swelling.

Correct answer: C

Rationale: Instruct the patient to splint the incision if he can't avoid sneezing or coughing to minimize the risk of complications after heriorrhaphy.

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