Nursing Elites

1. A nurse is performing an assessment on a client with a suspected diagnosis of acute pancreatitis. The nurse assesses the client, knowing that which of the following is a hallmark sign of this disorder?

• A. Severe abdominal pain relieved by vomiting
• B. Severe abdominal pain that is unrelieved by vomiting
• C. Hypothermia
• D. Epigastric pain radiating to the neck area

Correct answer: B

Rationale: A hallmark sign of acute pancreatitis is severe abdominal pain that is not relieved by vomiting. Nausea and vomiting are common presenting symptoms, with vomitus typically consisting of gastric and duodenal contents. Hypothermia is not a hallmark sign of acute pancreatitis. Fever, typically less than 38 degrees centigrade, is more common. Epigastric pain radiating to the neck area is not a characteristic sign of acute pancreatitis. Therefore, choice B is the correct answer.

2. The nurse is teaching the client how to perform a colostomy irrigation. To enhance the effectiveness of the irrigation and fecal returns, what measure should the nurse instruct the client to do?

• A. Increase fluid intake
• B. Reduce the amount of irrigation solution
• C. Perform the irrigation in the evening
• D. Place heat on the abdomen

Correct answer: A

Rationale: Increasing fluid intake helps to enhance the effectiveness of colostomy irrigation by softening the stool and promoting better fecal return.

3. You have a patient with achalasia (incomplete muscle relaxation of the GI tract, especially sphincter muscles). Which medications do you anticipate to administer?

• A. Isosorbide dinitrate (Isordil)
• B. Digoxin (Lanoxin)
• C. Captopril (Capoten)
• D. Propanolol (Inderal)

Correct answer: A

Rationale: Isosorbide dinitrate (Isordil) is a medication used to relax the muscles of the GI tract in patients with achalasia.

4. Jason, a 22 y.o. accident victim, requires an NG tube for feeding. What should you immediately do after inserting an NG tube for liquid enteral feedings?

• A. Aspirate for gastric secretions with a syringe.
• B. Begin feeding slowly to prevent cramping.
• C. Get an X-ray of the tip of the tube within 24 hours.
• D. Clamp off the tube until the feedings begin.

Correct answer: A

Rationale: Immediately after inserting an NG tube for enteral feedings, aspirate for gastric secretions to confirm proper placement.

5. Before bowel surgery, Lee is to administer enemas until clear. During administration, he complains of intestinal cramps. What do you do next?

• A. Discontinue the procedure.
• B. Lower the height of the enema container.
• C. Complete the procedure as quickly as possible.
• D. Continue administration of the enema as ordered without making any adjustments.

Correct answer: B

Rationale: If a patient complains of intestinal cramps during an enema, lowering the height of the enema container can help reduce discomfort.

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