Nursing Elites

1. A client with viral hepatitis is discussing with the nurse the need to avoid alcohol and states, 'I’m not sure I can avoid alcohol.' The most appropriate response is

• A. Everything will be alright.
• B. I think you should talk more with the doctor about this.
• C. I don’t believe that.
• D. I’m not sure that I don’t understand. Would you please explain?

Correct answer: D

Rationale: The most appropriate response in this situation is to seek clarification from the client by saying, 'I’m not sure that I don’t understand. Would you please explain?' This response shows empathy and a willingness to listen, encouraging the client to elaborate on their concerns. False reassurance (Choice A) is not helpful as it dismisses the client's feelings. Suggesting to talk more with the doctor (Choice B) may deflect from addressing the client's immediate concerns. Expressing disbelief (Choice C) can create a barrier to open communication, making the client feel unsupported.

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 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.

4. Which of the following diagnostic tests should be performed annually over age 50 to screen for colon cancer?

• A. Abdominal CT scan
• B. Abdominal x-ray
• C. Colonoscopy
• D. Fecal occult blood test

Correct answer: D

Rationale: A fecal occult blood test should be performed annually for individuals over age 50 to screen for colon cancer.

5. Brenda, a 36 y.o. patient is on your floor with acute pancreatitis. Treatment for her includes:

• A. Continuous peritoneal lavage.
• B. Regular diet with increased fat.
• C. Nutritional support with TPN.
• D. Insertion of a T tube to drain the pancreas.

Correct answer: C

Rationale: Treatment for acute pancreatitis includes nutritional support with TPN.

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