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. Your patient, Christopher, has a diagnosis of ulcerative colitis and has severe abdominal pain aggravated by movement, rebound tenderness, fever, nausea, and decreased urine output. This may indicate which complication?

• A. Fistula.
• B. Bowel perforation.
• C. Bowel obstruction.
• D. Abscess.

Correct answer: B

Rationale: Severe abdominal pain aggravated by movement, rebound tenderness, fever, nausea, and decreased urine output in a patient with ulcerative colitis may indicate bowel perforation.

3. A nurse is reviewing the orders of a client admitted to the hospital with a diagnosis of acute pancreatitis. Select the interventions that the nurse would expect to be prescribed for the client.

• A. Small, frequent high-calorie feedings.
• B. Meperidine (Demerol) as prescribed for pain.
• C. Place the client in a side-lying position with the head elevated 45-degrees.
• D. Administer antacids and anticholinergics to suppress gastrointestinal secretions.

Correct answer: B

Rationale: The correct intervention for a client with acute pancreatitis is to prescribe pain medications such as meperidine to manage the abdominal pain, which is a prominent symptom of the condition. The other options are incorrect because: A) Clients with acute pancreatitis are normally placed on NPO (nothing by mouth) status to rest the pancreas, so small, frequent high-calorie feedings are not indicated. C) Placing the client in a side-lying position with the head elevated 45-degrees helps decrease tension on the abdomen and may ease pain, but it is not a standard intervention for acute pancreatitis. D) Administering antacids and anticholinergics to suppress gastrointestinal secretions is not a routine intervention for acute pancreatitis.

4. Jason, a 22 y.o. accident victim, requires an NG tube for feeding. What should you immediately do after inserting an NG tube for liquid enteral feedings?

• A. Aspirate for gastric secretions with a syringe.
• B. Begin feeding slowly to prevent cramping.
• C. Get an X-ray of the tip of the tube within 24 hours.
• D. Clamp off the tube until the feedings begin.

Correct answer: A

Rationale: Immediately after inserting an NG tube for enteral feedings, aspirate for gastric secretions to confirm proper placement.

5. 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.

Similar Questions