Nursing Elites

1. You’re discharging Nathaniel with hepatitis B. Which statement suggests understanding by the patient?

• A. Now I can never get hepatitis again.
• B. I can safely give blood after 3 months.
• C. I’ll never have a problem with my liver again, even if I drink alcohol.
• D. My family knows that if I get tired and start vomiting, I may be getting sick again.

Correct answer: D

Rationale: Understanding that family needs to be aware of symptoms that may indicate a recurrence of hepatitis B shows proper understanding by the patient.

2. Annebell is being discharged with a colostomy, and you’re teaching her about colostomy care. Which statement correctly describes a healthy stoma?

• A. At first, the stoma may bleed slightly when touched.
• B. The stoma should appear dark and have a bluish hue.
• C. A burning sensation under the stoma faceplate is normal.
• D. The stoma should remain swollen away from the abdomen.

Correct answer: A

Rationale: A healthy stoma may bleed slightly when touched initially, which is normal.

3. The nurse is preparing to discontinue a client’s nasogastric tube. The client is positioned properly, and the tube has been flushed with 15 mL of air to clear secretions. Before removing the tube, the nurse makes which statement to the client?

• A. Take a deep breath when I tell you and breathe normally while I remove the tube.
• B. Take a deep breath when I tell you and bear down while I remove the tube.
• C. Take a deep breath when I tell you and slowly exhale while I remove the tube.
• D. Take a deep breath when I tell you and hold it while I remove the tube.

Correct answer: C

Rationale: The client should take a deep breath because the client’s airway will be obstructed temporarily during tube removal. The nurse then tells the client to exhale slowly and withdraws the tube during exhalation. Bearing down could inhibit the removal of the tube. Breathing normally could result in aspiration of gastric secretions during inhalation. Holding the breath does not facilitate tube removal.

4. The nurse is planning to teach the client with gastroesophageal reflux disease about substances that will increase the lower esophageal sphincter pressure. Which of the following items would the nurse include on this list?

• A. Fatty foods
• B. Nonfat milk
• C. Chocolate
• D. Coffee

Correct answer: B

Rationale: Foods that increase the lower esophageal sphincter (LES) pressure will decrease reflux, and lessen the symptoms of gastroesophageal reflux disease (GERD). The food substance that will increase the LES pressure is nonfat milk. The other substances listed decrease the LES pressure, thus increasing reflux symptoms. Aggravating substances include chocolate, coffee, fatty foods and alcohol.

5. Cholestyramine resin (Questran Light) is prescribed for the client with an elevated serum cholesterol level. The nurse would instruct the client to take the medication

• A. After meals.
• B. Mixed with fruit juice.
• C. Via rectal suppository.
• D. At least 3 hours before meals.

Correct answer: B

Rationale: Cholestyramine resin binds with bile salts in the intestines to form a compound that is excreted in the feces. The client should be instructed to mix the medication with 3 to 6 oz of water, milk, fruit juice, or soup. The medication should be administered before meals. The medication is not administered via rectal suppository.

Similar Questions