Nursing Elites

1. Which of the following conditions is most likely to directly cause peritonitis?

• A. Cholelithiasis
• B. Gastritis
• C. Perforated ulcer
• D. Incarcerated hernia

Correct answer: C

Rationale: A perforated ulcer is most likely to directly cause peritonitis due to the leakage of gastric contents into the peritoneal cavity.

2. The client with cirrhosis has ascites and excess fluid volume. Which measure will the nurse include in the plan of care for this client?

• A. Increase the amount of sodium in the diet.
• B. Limit the amount of fluids consumed.
• C. Encourage frequent ambulation.
• D. Administer magnesium antacids.

Correct answer: B

Rationale: Excess fluid volume, related to the accumulation of fluid in the peritoneal and dependent areas of the body, can occur in the client with cirrhosis. Fluids should be restricted, including fluids given in medications and meals. Sodium restriction also aids in reducing fluid volume excess.

3. The nurse has inserted a nasogastric tube to the level of the oropharynx and has repositioned the client’s head in a flexed-forward position. The client has been asked to begin swallowing. The nurse starts slowly to advance the nasogastric tube with each swallow. The client begins to cough, gag, and choke. Which nursing action would least likely result in proper tube insertion and promote client relaxation?

• A. Continuing to advance the tube to the desired distance
• B. Pulling the tube back slightly
• C. Checking the back of the pharynx using a tongue blade and flashlight.
• D. Instructing the client to breathe slowly and take sips of water.

Correct answer: A

Rationale: As the nasogastric tube is passed through the oropharynx, the gag reflex is stimulated, which may cause coughing, gagging, or choking. Instead of passing through to the esophagus, the nasogastric tube may coil around itself in the oropharynx, or it may enter the larynx and obstruct the airway, pulling the tube back slightly will remove it from the larynx; advancing the tube might position it in the trachea. Swallowing closes the epiglottis over the trachea and helps move the tube into the esophagus. Slow breathing helps the client relax to reduce the gag response. The nurse should check the back of the client’s throat to note if the tube has coiled. The tube may be advanced after the client relaxes.

4. The home care nurse is visiting a client with a diagnosis of pernicious anemia that developed as a result of gastric surgery. The nurse instructs the client that because the stomach lining produces a decreased amount of intrinsic factor in this disorder, the client will need

• A. Vitamin B12 injections
• B. Vitamin B6 injections
• C. An antibiotic
• D. An antacid

Correct answer: A

Rationale: A lack of intrinsic factor needed to absorb vitamin B12 occurs in pernicious anemia. Vitamin B12 is needed for the maturation of red blood cells. Vitamin B6 is not necessarily needed for pernicious anemia and can be taken orally. An antibiotic and antacids may be prescribed for certain types of gastric ulcers.

5. Which of the following symptoms is common with a hiatal hernia?

• A. Left arm pain
• B. Lower back pain
• C. Esophageal reflux
• D. Abdominal cramping

Correct answer: C

Rationale: Esophageal reflux is a common symptom of a hiatal hernia because the hernia can cause stomach acid to move back up into the esophagus.

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