Nursing Elites

1. A client with viral hepatitis has no appetite, and food makes the client nauseated. Which of the following interventions would be most appropriate?

• A. Explain that high-fat diets usually are tolerated better.
• B. Encourage intake of foods high in protein.
• C. Explain that the majority of calories need to be consumed in the evening hours.
• D. Monitor for fluid and electrolyte imbalance.

Correct answer: D

Rationale: If nausea occurs and persists, the client will need to be assessed for fluid and electrolyte imbalance. Explaining to the client that the majority of calories should be eaten in the morning hours is important because nausea occurs most often in the afternoon and evening. Clients should select a diet high in calories because energy is required for healing. Protein increases the workload on the liver. Changes in bilirubin interfere with fat absorption, so low-fat diets are tolerated better.

2. The nurse is caring for a client admitted to the hospital with a suspected diagnosis of acute appendicitis. Which of the following laboratory results would the nurse expect to note if the client indeed has appendicitis?

• A. Leukopenia with a shift to the right
• B. Leukocytosis with a shift to the right
• C. Leukocytosis with a shift to the left
• D. Leukopenia with a shift to the left

Correct answer: C

Rationale: Laboratory findings do not establish the diagnosis of appendicitis, but often moderate elevation of the white blood cell count (leukocytosis) to 10,000 to 18,000 cells/mm3 occurs with a “shift to the left” (an increased number of immature white blood cells.).

3. The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To determine whether the problem is currently active, the nurse would assess the client for which of the following most frequent symptom(s) of duodenal ulcer?

• A. Pain that is relieved by food intake
• B. Pain that radiated down the right arm
• C. N/V
• D. Weight loss

Correct answer: A

Rationale: Pain that is relieved by food intake is the most frequent symptom of duodenal ulcers because the food neutralizes the stomach acid.

4. Matt is a 49 y.o. with a hiatal hernia that you are about to counsel. Health care counseling for Matt should include which of the following instructions?

• A. Restrict intake of high-carbohydrate foods.
• B. Increase fluid intake with meals.
• C. Increase fat intake.
• D. Eat three regular meals a day.

Correct answer: D

Rationale: For a patient with a hiatal hernia, it is important to eat three regular meals a day to prevent symptoms.

5. A patient has an acute upper GI hemorrhage. Your interventions include:

• A. Treating hypovolemia.
• B. Treating hypervolemia.
• C. Controlling the bleeding source.
• D. Treating shock and diagnosing the bleeding source.

Correct answer: D

Rationale: For a patient with an acute upper GI hemorrhage, your interventions include treating shock and diagnosing the bleeding source.

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