Nursing Elites

1. You’re caring for Jane, a 57 y.o. patient with liver cirrhosis who develops ascites and requires paracentesis. Before her paracentesis, you instruct her to:

• A. Empty her bladder.
• B. Lie supine in bed.
• C. Remain NPO for 4 hours.
• D. Clean her bowels with an enema.

Correct answer: A

Rationale: Before paracentesis, instruct the patient to empty her bladder to avoid bladder injury during the procedure.

2. A client with peptic ulcer disease tells the nurse that he has black stools, which he has not reported to his physician. Based on this information, which nursing diagnosis would be appropriate for this client?

• A. Ineffective coping related to fear of diagnosis of chronic illness
• B. Deficient knowledge related to unfamiliarity with significant signs and symptoms
• C. Constipation related to decreased gastric motility
• D. Imbalanced nutrition: Less than body requirements due to gastric bleeding

Correct answer: B

Rationale: Deficient knowledge related to unfamiliarity with significant signs and symptoms is appropriate because the client did not report the black stools, which can be a sign of bleeding.

3. The nurse is assessing for stoma prolapse in a client with a colostomy. The nurse would observe which of the following if stoma prolapse occurred?

• A. Sunken and hidden stoma
• B. Dark- and bluish-colored stoma
• C. Narrowed and flattened stoma
• D. Protruding stoma

Correct answer: D

Rationale: A protruding stoma is indicative of stoma prolapse, which occurs when the bowel protrudes excessively through the stoma.

4. When preparing the client with hepatitis A for extended convalescence, the nurse teaches the client about problems that may occur. The nurse knows that the client has understood the teaching when he says that he is most likely to have difficulty:

• A. Controlling abdominal pain.
• B. Maintaining a regular bowel elimination pattern.
• C. Preventing respiratory complications.
• D. Maintaining a positive, optimistic outlook.

Correct answer: D

Rationale: Convalescence after hepatitis A may take weeks or even months. Boredom and depression are common problems that the client should anticipate. Abdominal pain is not usually a symptom of hepatitis A. Maintaining a regular bowel elimination pattern is not usually a problem with hepatitis. Problems preventing respiratory complications are unlikely. To support healing, activity is strictly limited but bed rest is not prescribed.

5. A nurse is reviewing the orders of a client admitted to the hospital with a diagnosis of acute pancreatitis. Select the interventions that the nurse would expect to be prescribed for the client.

• A. Small, frequent high-calorie feedings.
• B. Meperidine (Demerol) as prescribed for pain.
• C. Place the client in a side-lying position with the head elevated 45-degrees.
• D. Administer antacids and anticholinergics to suppress gastrointestinal secretions.

Correct answer: B

Rationale: The correct intervention for a client with acute pancreatitis is to prescribe pain medications such as meperidine to manage the abdominal pain, which is a prominent symptom of the condition. The other options are incorrect because: A) Clients with acute pancreatitis are normally placed on NPO (nothing by mouth) status to rest the pancreas, so small, frequent high-calorie feedings are not indicated. C) Placing the client in a side-lying position with the head elevated 45-degrees helps decrease tension on the abdomen and may ease pain, but it is not a standard intervention for acute pancreatitis. D) Administering antacids and anticholinergics to suppress gastrointestinal secretions is not a routine intervention for acute pancreatitis.

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