Nursing Elites

1. Which goal of the client’s care should take priority during the first days of hospitalization for an exacerbation of ulcerative colitis?

• A. Promoting self-care and independence
• B. Managing diarrhea
• C. Maintaining adequate nutrition
• D. Promoting rest and comfort

Correct answer: B

Rationale: Managing diarrhea should take priority during the first days of hospitalization for an exacerbation of ulcerative colitis.

2. Which of the following symptoms would a client in the early stages of peritonitis exhibit?

• A. Abdominal distention
• B. Abdominal pain and rigidity
• C. Hyperactive bowel sounds
• D. Right upper quadrant pain

Correct answer: B

Rationale: In the early stages of peritonitis, the client would exhibit abdominal pain and rigidity due to inflammation.

3. You’re advising a 21 y.o. with a colostomy who reports problems with flatus. What food should you recommend?

• A. Peas
• B. Cabbage
• C. Broccoli
• D. Yogurt

Correct answer: D

Rationale: Yogurt can help reduce problems with flatus in patients with a colostomy.

4. A nurse has been caring for a client with a Sengstaken-Blakemore tube. The physician arrives on the nursing unit and deflates the esophageal balloon. The nurse should monitor the client most closely for which of the following?

• A. Swelling of the abdomen
• B. Bloody diarrhea
• C. Vomiting blood
• D. An elevated temperature and arise in blood pressure

Correct answer: C

Rationale: A Sengstaken-Blakemore tube is inserted into a client with a diagnosis of cirrhosis and ruptured esophageal varices. The tube has an esophageal and a gastric balloon. The esophageal balloon exerts pressure on the bleeding. The pressure of the esophageal balloon is released at intervals to decrease the risk of trauma to esophageal tissues, including esophageal rupture or necrosis. When the balloon is deflated the client may begin to bleed again from the esophageal varices, noted by vomiting of blood.

5. A Penrose drain is in place on the first postoperative day following a cholecystectomy. Serosanguineous drainage is noted on the dressing covering the drain. Which nursing intervention is most appropriate?

• A. Notify the physician.
• B. Change the dressing.
• C. Circle the amount on the dressing with a pen.
• D. Continue to monitor the drainage.

Correct answer: B

Rationale: Serosanguineous drainage with a small amount of bile is expected from the Penrose drain for the first 24 hours. Drainage then decreases, and the drain is removed usually within 48 hours. The nurse does not need to notify the physician. A sterile dressing covers the site and should be changed to prevent infection and skin excoriation.

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