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. When assessing the client with celiac disease, the nurse can expect to find which of the following?

• A. Steatorrhea
• B. Jaundiced sclerae
• C. Clay-colored stools
• D. Widened pulse pressure

Correct answer: A

Rationale: Because celiac disease destroys the absorbing surface of the intestine, fat isn't absorbed but is passed in the stool. Steatorrhea is bulky, fatty stools that have a foul odor. Jaundiced sclerae result from elevated bilirubin levels. Clay-colored stools are seen with biliary disease when bile flow is blocked. Celiac disease doesn't cause a widened pulse pressure.

3. Stephen is a 62 y.o. patient that has had a liver biopsy. Which of the following groups of signs alert you to a possible pneumothorax?

• A. Dyspnea and reduced or absent breath sounds over the right lung
• B. Tachycardia, hypotension, and cool, clammy skin
• C. Fever, rebound tenderness, and abdominal rigidity
• D. Redness, warmth, and drainage at the biopsy site

Correct answer: A

Rationale: Dyspnea and reduced or absent breath sounds over the right lung are signs of a possible pneumothorax.

4. The client with Crohn’s disease has a nursing diagnosis of Acute Pain. The nurse would teach the client to avoid which of the following in managing this problem?

• A. Lying supine with the legs straight
• B. Massaging the abdomen
• C. Using antispasmodic medication
• D. Using relaxation techniques

Correct answer: A

Rationale: In managing acute pain associated with Crohn’s disease, the client should avoid lying supine with the legs straight. This position increases muscle tension in the abdomen, potentially aggravating inflamed intestinal tissues as the abdominal muscles are stretched. Massaging the abdomen, using antispasmodic medication, and employing relaxation techniques are beneficial in alleviating pain. Massaging can help relax abdominal muscles, antispasmodic medication can reduce spasms contributing to pain, and relaxation techniques aid in overall pain management. Therefore, choices B, C, and D are appropriate interventions for managing pain in clients with CroCrohn’s disease.

5. Eleanor, a 62 y.o. woman with diverticulosis is your patient. Which interventions would you expect to include in her care?

• A. Low-fiber diet and fluid restrictions.
• B. Total parenteral nutrition and bed rest.
• C. High-fiber diet and administration of psyllium.
• D. Administration of analgesics and antacids.

Correct answer: C

Rationale: Care for a patient with diverticulosis includes a high-fiber diet and administration of psyllium.

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