Nursing Elites

1. The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis. The client is scheduled for surgery for 2 hours. The client begins to complain of increases abdominal pain and begins to vomit. On assessment the nurse notes that the abdomen distended and bowel sounds are diminished. Which of the following is the most appropriate nursing intervention?

• A. Administer the prescribed pain medication.
• B. Notify the physician.
• C. Call and ask the operating room team to perform the surgery as soon as possible.
• D. Reposition the client and apply a heating pad on warm setting to the client’s abdomen.

Correct answer: B

Rationale: Based on the signs and symptoms presented in the question, the nurse should suspect peritonitis and should notify the physician. Administering pain medication is not an appropriate intervention. Heat should never be applied to the abdomen of a client with suspected appendicitis. Scheduling surgical time is not within the scope of nursing practice, although the physician probably would perform the surgery earlier than the prescheduled time.

2. An enema is prescribed for a client with suspected appendicitis. Which of the following actions should the nurse take?

• A. Prepare 750 ml of irrigating solution warmed to 100*F
• B. Question the physician about the order
• C. Provide privacy and explain the procedure to the client
• D. Assist the client to left lateral Sim’s position

Correct answer: B

Rationale: An enema is contraindicated in clients with suspected appendicitis because it can increase the risk of perforation. It is important to verify the appropriateness of this order with the physician.

3. Which of the following associated disorders may the client with Crohn’s disease exhibit?

• A. Ankylosing spondylitis
• B. Colon cancer
• C. Malabsorption
• D. Lactase deficiency

Correct answer: A

Rationale: Clients with Crohn's disease may exhibit associated disorders such as ankylosing spondylitis, which is an inflammatory condition affecting the spine.

4. If a gastric acid perforates, which of the following actions should not be included in the immediate management of the client?

• A. Blood replacement
• B. Antacid administration
• C. Nasogastric tube suction
• D. Fluid and electrolyte replacement

Correct answer: B

Rationale: Antacid administration should not be included in the immediate management of a gastric perforation.

5. Which of the following definitions best describes gastritis?

• A. Erosion of the gastric mucosa
• B. Inflammation of a diverticulum
• C. Inflammation of the gastric mucosa
• D. Reflux of stomach acid into the esophagus

Correct answer: C

Rationale: The correct answer is C: 'Inflammation of the gastric mucosa.' Gastritis is characterized by inflammation of the stomach lining, specifically the gastric mucosa. This inflammation can be caused by various factors such as infections, medications, alcohol, or autoimmune diseases. Choice A, 'Erosion of the gastric mucosa,' is incorrect because erosion refers to the wearing away of tissue rather than inflammation. Choice B, 'Inflammation of a diverticulum,' is incorrect because gastritis specifically involves inflammation of the stomach lining, not a diverticulum. Choice D, 'Reflux of stomach acid into the esophagus,' describes gastroesophageal reflux disease (GERD), which is different from gastritis.

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