Nursing Elites

1. A client with which of the following conditions may be likely to develop rectal cancer?

• A. Adenomatous polyps
• B. Diverticulitis
• C. Hemorrhoids
• D. Peptic ulcer disease

Correct answer: A

Rationale: Adenomatous polyps are a known risk factor for the development of rectal cancer.

2. Your patient, Christopher, has a diagnosis of ulcerative colitis and has severe abdominal pain aggravated by movement, rebound tenderness, fever, nausea, and decreased urine output. This may indicate which complication?

• A. Fistula.
• B. Bowel perforation.
• C. Bowel obstruction.
• D. Abscess.

Correct answer: B

Rationale: Severe abdominal pain aggravated by movement, rebound tenderness, fever, nausea, and decreased urine output in a patient with ulcerative colitis may indicate bowel perforation.

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. A client with peptic ulcer is scheduled for a Vagotomy. The client asks the nurse about the purpose of this procedure. The nurse tells the client that the procedure

• A. Decreases food absorption in the stomach.
• B. Heals the gastric mucosa.
• C. Halts stress reactions.
• D. Reduces the stimulus to acid secretions.

Correct answer: D

Rationale: A vagotomy, or cutting of the vagus nerve, is done to eliminate parasympathetic stimulation of gastric secretion, thereby reducing the stimulus to acid secretions. Options A, B, and C are incorrect as a vagotomy does not affect food absorption, heal the gastric mucosa, or halt stress reactions.

5. The physician orders a Salem sump tube for gastrointestinal intubation. The nurse prepares for the insertion and obtains which of the following items from the supply room?

• A. A tube with a single lumen that connects to suction
• B. A tube with a large lumen and an air vent
• C. A Sengstaken-Blakemore tube
• D. A Dobbhoff weighted tube

Correct answer: B

Rationale: A tube with a large lumen and an air vent is a Salem sump tube. A tube with a single lumen is called a Levin’s tube. A Sengstaken-Blakemore tube is used to control bleeding in the esophagus. A Dobbhoff weighted tube is used for feedings.

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