Nursing Elites

1. The nurse is caring for a client with cirrhosis. Which manifestations indicate deficient vitamin K absorption caused by this liver disease?

• A. Dyspnea and fatigue
• B. Ascites and orthopnea
• C. Purpura and petechiae
• D. Gynecomastia and testicular atrophy

Correct answer: C

Rationale: A liver disorder, such as cirrhosis, can disrupt the liver's normal use of vitamin K to produce prothrombin (a clotting factor). Because of this, the nurse should monitor the client for signs of bleeding, including purpura and petechiae. Dyspnea and fatigue suggest anemia. Ascites and orthopnea are unrelated to vitamin K absorption. Gynecomastia and testicular atrophy result from decreased estrogen metabolism by the diseased liver.

2. Your patient with peritonitis is NPO and complaining of thirst. What is your priority?

• A. Increase the I.V. infusion rate.
• B. Use diversion activities.
• C. Provide frequent mouth care.
• D. Give ice chips every 15 minutes.

Correct answer: C

Rationale: Providing frequent mouth care is the priority for a patient with peritonitis who is NPO and complaining of thirst.

3. Your patient has a GI tract that is functioning, but has the inability to swallow foods. Which is the preferred method of feeding for your patient?

• A. TPN
• B. PPN
• C. NG feeding
• D. Oral liquid supplements

Correct answer: C

Rationale: NG feeding is the preferred method for patients with a functioning GI tract but an inability to swallow foods.

4. The client with a colostomy has an order for irrigation of the colostomy. The nurse uses which solution for the irrigation?

• A. Distilled water
• B. Tap water
• C. Sterile water
• D. Lactated Ringer’s

Correct answer: B

Rationale: The correct solution to use for the irrigation of a colostomy is warm tap water or saline solution. If tap water is not suitable for drinking, bottled water can be used. Distilled water, sterile water, and Lactated Ringer’s are not appropriate solutions for colostomy irrigation. Distilled water lacks essential minerals, sterile water may not provide adequate cleaning, and Lactated Ringer’s is not indicated for this procedure.

5. The nurse would assess the client experiencing an acute episode of cholecystitis for pain that is located in the right:

• A. Upper quadrant and radiates to the left scapula and shoulder
• B. Upper quadrant and radiates to the right scapula and shoulder
• C. Lower quadrant and radiates to the umbilicus
• D. Lower quadrant and radiates to the back

Correct answer: B

Rationale: Pain from cholecystitis is typically located in the right upper quadrant and may radiate to the right scapula and shoulder.

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