Nursing Elites

1. Which of the following conditions can cause a hiatal hernia?

• A. Increased intrathoracic pressure
• B. Weakness of the esophageal muscle
• C. Increased esophageal muscle pressure
• D. Weakness of the diaphragmic muscle

Correct answer: D

Rationale: Weakness of the diaphragmic muscle can lead to a hiatal hernia as it allows part of the stomach to push through the diaphragm into the chest cavity.

2. After a right hemicolectomy for treatment of colon cancer, a 57-year old client is reluctant to turn while on bed rest. Which action by the nurse would be appropriate?

• A. Asking a co-worker to help turn the client
• B. Explaining to the client why turning is important.
• C. Allowing the client to turn when he’s ready to do so
• D. Telling the client that the physician’s order states he must turn every 2 hours

Correct answer: B

Rationale: Educating the client about the importance of turning can encourage compliance and promote understanding of the necessity to prevent complications such as pressure ulcers and pneumonia.

3. During the assessment of a client’s mouth, the nurse notes the absence of saliva. The client is also complaining of pain near the area of the ear. The client has been NPO for several days because of the insertion of an NG tube. Based on these findings, the nurse suspects that the client is developing which of the following mouth conditions?

• A. Stomatitis
• B. Oral candidiasis
• C. Parotitis
• D. Gingivitis

Correct answer: C

Rationale: The correct answer is C, Parotitis. Parotitis, inflammation of the parotid glands, can occur due to the absence of saliva and dehydration, often associated with being NPO and having an NG tube. Stomatitis (choice A) is inflammation of the oral mucosa, not specifically related to absent saliva. Oral candidiasis (choice B) is a fungal infection that can occur in the mouth, not directly related to the absence of saliva. Gingivitis (choice D) is inflammation of the gums and is not typically associated with the absence of saliva and dehydration.

4. You have to teach ostomy self care to a patient with a colostomy. You tell the patient to measure and cut the wafer:

• A. To the exact size of the stoma.
• B. About 1/16” larger than the stoma.
• C. About 1/8” larger than the stoma.
• D. About 1/4″ larger than the stoma.

Correct answer: C

Rationale: The wafer should be measured and cut about 1/8” larger than the stoma to ensure proper fit and prevent skin irritation.

5. Which of the following nursing measures would be inappropriate when caring for a client with a Cantor tube?

• A. Injecting 10 mL of air into the tube to facilitate drainage.
• B. Applying a water-soluble lubricant to the client's nares.
• C. Coiling extra tubing on the client's bed.
• D. Irrigating the tube with 50 mL of normal saline solution.

Correct answer: D

Rationale: Intestinal tubes are not irrigated. Injecting air into the tube, applying water-soluble lubricant, and coiling extra tubing are appropriate nursing measures.

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