Nursing Elites

1. Your patient recently had abdominal surgery and tells you that he feels a popping sensation in his incision during a coughing spell, followed by severe pain. You anticipate an evisceration. Which supplies should you take to his room?

• A. A suture kit.
• B. Sterile water and a suture kit.
• C. Sterile water and sterile dressings.
• D. Sterile saline solution and sterile dressings.

Correct answer: D

Rationale: For a suspected evisceration, sterile saline solution and sterile dressings should be taken to the patient's room to cover the wound and keep it moist.

2. If a client had irritable bowel syndrome, which of the following diagnostic tests would determine if the diagnosis is Crohn’s disease or ulcerative colitis?

• A. Abdominal computed tomography (CT) scan
• B. Abdominal x-ray
• C. Barium swallow
• D. Colonoscopy with biopsy

Correct answer: D

Rationale: A colonoscopy with biopsy is the most definitive diagnostic test to differentiate between Crohn's disease and ulcerative colitis.

3. 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.

4. To accurately assess for jaundice in a patient with dark skin pigmentation, the nurse should examine which body areas?

• A. Nail beds
• B. Skin on the back of the hand
• C. Hard palate of the mouth
• D. Soles of the feet

Correct answer: C

Rationale: To accurately assess for jaundice in a patient with dark skin pigmentation, the nurse should examine the hard palate of the mouth. Jaundice is best assessed in the sclera; however, in dark-skinned patients, normal yellow pigmentation may be present in the sclera, making it difficult to detect jaundice. Inspection of the hard palate for a yellow color can confirm the presence of jaundice. Cyanosis is best observed in the nail beds, not indicative of jaundice. While skin on the palm of the hand can indicate jaundice, the back of the hand is not a typical area for assessment. Jaundice can be assessed on the soles of the feet in dark-skinned patients, but it is better visualized in the hard palate for accurate evaluation.

5. A client being treated for chronic cholecystitis should be given which of the following instructions?

• A. Increase rest
• B. Avoid antacids
• C. Increase protein in diet
• D. Use anticholinergics as prescribed

Correct answer: D

Rationale: Using anticholinergics as prescribed can help manage the symptoms of chronic cholecystitis.

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