Nursing Elites

1. Which of the following symptoms may be exhibited by a client with Crohn’s disease?

• A. Bloody diarrhea
• B. Narrow stools
• C. N/V
• D. Steatorrhea

Correct answer: D

Rationale: Clients with Crohn's disease may exhibit symptoms such as steatorrhea, which is the presence of excess fat in the stool.

2. 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.

3. A patient who underwent abdominal surgery now has a gaping incision due to delayed wound healing. Which method is correct when you irrigate a gaping abdominal incision with sterile normal saline solution, using a piston syringe?

• A. Rapidly instill a stream of irrigating solution into the wound.
• B. Apply a wet-to-dry dressing to the wound after the irrigation.
• C. Moisten the area around the wound with normal saline solution after the irrigation.
• D. Irrigate continuously until the solution becomes clear or all of the solution is used.

Correct answer: D

Rationale: Irrigating continuously until the solution becomes clear or all of the solution is used is the correct method when irrigating a gaping abdominal incision.

4. A nurse is inserting a nasogastric tube in an adult client. During the procedure, the client begins to cough and has difficulty breathing. Which of the following is the most appropriate nursing action?

• A. Remove the tube and reinsert when the respiratory distress subsides.
• B. Pull back on the tube and wait until the respiratory distress subsides.
• C. Quickly insert the tube.
• D. Notify the physician immediately.

Correct answer: B

Rationale: During the insertion of a nasogastric tube, if the client experiences difficulty breathing or any respiratory distress, withdraw the tube slightly, stop the tube advancement, and wait until the distress subsides. Options 1 and 4 are unnecessary. Quickly inserting the tube is not an appropriate action because, in this situation, it may be likely that the tube has entered the bronchus.

5. You’re caring for Lewis, a 67 y.o. patient with liver cirrhosis who develops ascites and requires paracentesis. Relief of which symptom indicated that the paracentesis was effective?

• A. Pruritus
• B. Dyspnea
• C. Jaundice
• D. Peripheral Neuropathy

Correct answer: B

Rationale: Dyspnea relief indicates that the paracentesis was effective in reducing ascites.

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