Nursing Elites

1. The nurse is caring for a client on the first postoperative day following a surgical repair of an abdominal aortic aneurysm. Which nursing diagnosis is the most important for this client?

• A. Risk for infection
• B. Deficient knowledge
• C. Ineffective peripheral tissue perfusion
• D. Activity intolerance

Correct answer: C

Rationale: Peripheral tissue perfusion is a major concern in the postoperative period following an abdominal aneurysm repair. Peripheral pulses should be checked frequently during the first 24 hours. A weak or absent pulse may be a sign of embolization or graft closure, especially if accompanied by a pale, cold, mottled extremity; the nurse should immediately report this to the surgeon. Risk for infection, deficient knowledge, and activity intolerance are all important nursing diagnoses in the postoperative period, but peripheral tissue perfusion is the most immediate concern.

2. A patient with chronic alcohol abuse is admitted with liver failure. You closely monitor the patient’s blood pressure because of which change that is associated with the liver failure?

• A. Hypoalbuminemia
• B. Increased capillary permeability
• C. Abnormal peripheral vasodilation
• D. Excess rennin release from the kidneys

Correct answer: C

Rationale: Abnormal peripheral vasodilation is a change associated with liver failure that requires close monitoring of the patient's blood pressure.

3. After a subtotal gastrectomy, care of the client’s nasogastric tube and drainage system should include which of the following nursing interventions?

• A. Irrigate the tube with 30 ml of sterile water every hour, if needed.
• B. Reposition the tube if it is not draining well
• C. Monitor the client for N/V, and abdominal distention
• D. Turn the machine to high suction of the drainage is sluggish on low suction.

Correct answer: C

Rationale: Monitoring the client for nausea, vomiting, and abdominal distention is crucial for ensuring proper functioning of the nasogastric tube and drainage system.

4. When a client has peptic ulcer disease, the nurse would expect a priority intervention to be:

• A. Assisting in inserting a Miller-Abbott tube
• B. Assisting in inserting an arterial pressure line
• C. Inserting a nasogastric tube
• D. Inserting an I.V.

Correct answer: C

Rationale: Inserting a nasogastric tube is a priority intervention for a client with peptic ulcer disease to decompress the stomach.

5. The nurse is caring for a client with chronic gastritis. The nurse monitors the client, knowing that this client is at risk for which of the following vitamin deficiencies?

• A. Vitamin A
• B. Vitamin B12
• C. Vitamin C
• D. Vitamin E

Correct answer: B

Rationale: Clients with chronic gastritis are at risk for Vitamin B12 deficiency due to impaired absorption.

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