Nursing Elites

1. Nathaniel has severe pruritus due to having hepatitis B. What is the best intervention for his comfort?

• A. Give tepid baths.
• B. Avoid lotions and creams.
• C. Use hot water to increase vasodilation.
• D. Use cold water to decrease the itching.

Correct answer: A

Rationale: Giving tepid baths can help soothe severe pruritus due to hepatitis B.

2. The nurse is evaluating the plan of care for a client with peptic ulcer disease with a nursing diagnosis of Acute Pain. The nurse would determine that the client has not met the expected outcomes if the client states

• A. That pain is relieved with histamine H2 receptor antagonists.
• B. That irritating foods have been eliminated from the diet.
• C. The client is being awakened at 2 AM with heartburn.
• D. The client has absence of pain before meals.

Correct answer: C

Rationale: Expected outcomes for the client with peptic ulcer disease experiencing pain include elimination of irritating foods from the diet, ability to take prescribed medications that will reduce pain, reporting that the pain is relieved or prevented with medication, and an ability to sleep through the night without pain. The client who continues to be awakened by pain requires further modification of medication therapy, which may include adjustment of timing of histamine H2 receptor antagonist or an additional dose of antacid before the time when pain awakens the client.

3. Which of the following symptoms is a client with colon cancer most likely to exhibit?

• A. A change in appetite
• B. A change in bowel habits
• C. An increase in body weight
• D. An increase in body temperature

Correct answer: B

Rationale: A change in bowel habits is the most common symptom of colon cancer.

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. Which of the following nursing interventions should be implemented to manage a client with appendicitis?

• A. Assessing for pain
• B. Encouraging oral intake of clear fluids
• C. Providing discharge teaching
• D. Assessing for symptoms of peritonitis

Correct answer: D

Rationale: The correct answer is D: Assessing for symptoms of peritonitis. This intervention is crucial in managing a client with appendicitis because it indicates a possible rupture of the inflamed appendix. Symptoms of peritonitis include severe abdominal pain, fever, nausea, vomiting, and abdominal rigidity. Prompt recognition of these symptoms is essential for timely intervention and surgical management. Choices A, B, and C are incorrect because while assessing for pain is important, assessing for symptoms of peritonitis takes precedence due to the critical nature of appendicitis. Encouraging oral intake of clear fluids and providing discharge teaching are not immediate priorities in the management of a client with acute appendicitis.

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