Nursing Elites

1. Rob is a 46 y.o. admitted to the hospital with a suspected diagnosis of Hepatitis B. He’s jaundiced and reports weakness. Which intervention will you include in his care?

• A. Regular exercise.
• B. A low-protein diet.
• C. Allow patient to select his meals.
• D. Rest period after small, frequent meals.

Correct answer: D

Rationale: For a patient with hepatitis B who is jaundiced and reports weakness, providing rest periods after small, frequent meals is important.

2. A client is suspected of having hepatitis. Which diagnostic test results will assist in confirming this diagnosis?

• A. Decreased erythrocyte sedimentation rate
• B. Elevated serum bilirubin
• C. Elevated hemoglobin
• D. Elevated blood urea nitrogen

Correct answer: B

Rationale: Laboratory indicators of hepatitis include elevated liver enzyme levels, elevated serum bilirubin levels, elevated erythrocyte sedimentation rates, and leucopenia. An elevated blood urea nitrogen may indicate renal dysfunction. A hemoglobin level is unrelated to this diagnosis.

3. After abdominal surgery, your patient has a severe coughing episode that causes wound evisceration. In addition to calling the doctor, which intervention is most appropriate?

• A. Irrigate the wound & organs with Betadine.
• B. Cover the wound with a saline soaked sterile dressing.
• C. Apply a dry sterile dressing & binder.
• D. Push the organs back & cover with moist sterile dressings.

Correct answer: B

Rationale: Covering the wound with a saline soaked sterile dressing is the most appropriate intervention for wound evisceration.

4. The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis. The client is scheduled for surgery for 2 hours. The client begins to complain of increases abdominal pain and begins to vomit. On assessment the nurse notes that the abdomen distended and bowel sounds are diminished. Which of the following is the most appropriate nursing intervention?

• A. Administer the prescribed pain medication.
• B. Notify the physician.
• C. Call and ask the operating room team to perform the surgery as soon as possible.
• D. Reposition the client and apply a heating pad on warm setting to the client’s abdomen.

Correct answer: B

Rationale: Based on the signs and symptoms presented in the question, the nurse should suspect peritonitis and should notify the physician. Administering pain medication is not an appropriate intervention. Heat should never be applied to the abdomen of a client with suspected appendicitis. Scheduling surgical time is not within the scope of nursing practice, although the physician probably would perform the surgery earlier than the prescheduled time.

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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