Nursing Elites

1. Your patient with peritonitis is NPO and complaining of thirst. What is your priority?

• A. Increase the I.V. infusion rate.
• B. Use diversion activities.
• C. Provide frequent mouth care.
• D. Give ice chips every 15 minutes.

Correct answer: C

Rationale: The correct answer is C: Provide frequent mouth care. In a patient with peritonitis who is NPO and thirsty, the priority is to maintain oral hygiene and provide comfort by moistening the mouth with frequent mouth care. This helps alleviate the sensation of thirst and maintains oral health. Increasing the IV infusion rate (choice A) may not address the patient's discomfort directly related to thirst. Using diversion activities (choice B) is not as critical as addressing the patient's immediate need for oral care. Giving ice chips every 15 minutes (choice D) is not recommended for a patient with peritonitis who is NPO, as it can lead to complications or worsen the condition.

2. The nurse is caring for a client with a diagnosis of cirrhosis and is monitoring the client for signs of portal hypertension. Which initial sign, if noted in the client, indicates the presence of portal hypertension?

• A. Flat neck veins
• B. Hypotension
• C. Weak pulse
• D. Crackles on auscultation of the lungs

Correct answer: D

Rationale: Clinical signs and symptoms or portal hypertension are identical to those of heart failure and include jugular vein distention, lung crackles, and decreased perfusion to all organs. Initially, the client may have hypertension, flushed skin, and a bounding pulse.

3. The student nurse is teaching the family of a patient with liver failure. You instruct them to limit which foods in the patient’s diet?

• A. Meats and beans.
• B. Butter and gravies.
• C. Potatoes and pastas.
• D. Cakes and pastries.

Correct answer: A

Rationale: For a patient with liver failure, it is important to limit the intake of meats and beans to reduce the risk of hepatic encephalopathy.

4. The hospitalized client with gastroesophageal reflux disease is complaining of chest discomfort that feels like heartburn following a meal. After administering an ordered antacid, the nurse encourages the client to lie in which of the following positions?

• A. Supine with the head of the bed flat
• B. On the stomach with the head flat
• C. On the left side with the head of the bed elevated 30 degrees
• D. On the right side with the head of the bed elevated 30 degrees

Correct answer: C

Rationale: The discomfort of reflux is aggravated by positions that compress the abdomen and the stomach. Lying flat on the back (supine) or on the stomach (prone) after a meal can exacerbate symptoms. Similarly, lying on the right side can worsen reflux. The most appropriate position to alleviate discomfort in a client with gastroesophageal reflux disease is lying on the left side with the head of the bed elevated at a 30-degree angle. This position helps prevent the backflow of stomach contents into the esophagus, providing relief to the client.

5. You are developing a careplan on Sally, a 67 y.o. patient with hepatic encephalopathy. Which of the following do you include?

• A. Administering a lactulose enema as ordered.
• B. Encouraging a protein-rich diet.
• C. Administering sedatives, as necessary.
• D. Encouraging ambulation at least four times a day.

Correct answer: A

Rationale: Administering a lactulose enema as ordered helps reduce ammonia levels in patients with hepatic encephalopathy.

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