Nursing Elites

1. The nurse is performing an assessment on a client with acute pancreatitis who was admitted to the hospital. Which of the following assessment questions most specifically would elicit information regarding the pain that is associated with acute pancreatitis?

• A. Does the pain in your abdomen radiate to your groin.
• B. Does the pain in your stomach radiate to the back?
• C. Does the pain in your stomach radiate to your lower middle abdomen?
• D. Does the pain in your lower abdomen radiate to the hip?

Correct answer: B

Rationale: The pain that is associated with acute pancreatitis is often severe and is located in the epigastric region and radiates to the back. Options 1, 3, and 4 are incorrect because they are not specific for the pain experienced by the client with pancreatitis.

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

• A. Administer dilaudid
• 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 a warm setting to the client’s abdomen.

Correct answer: B

Rationale: The symptoms suggest possible perforation or peritonitis, which are serious complications requiring immediate medical attention. The nurse should promptly notify the physician.

3. Which of the following nursing interventions should have the highest priority during the first hour after the admission of a client with cholecystitis who is experiencing pain, nausea, and vomiting?

• A. Administering pain medication.
• B. Completing the admission history.
• C. Maintaining hydration.
• D. Teaching about planned diagnostic tests.

Correct answer: A

Rationale: Administering pain medication would have the highest priority during the first hour after the client's admission. Pain relief is essential to address the client's immediate discomfort and distress. Completing the admission history, maintaining hydration, and teaching about planned diagnostic tests are important aspects of care but can be addressed after addressing the client's pain and stabilizing their condition.

4. Ralph has a history of alcohol abuse and has acute pancreatitis. Which lab value is most likely to be elevated?

• A. Calcium
• B. Glucose
• C. Magnesium
• D. Potassium

Correct answer: B

Rationale: In a patient with acute pancreatitis and a history of alcohol abuse, glucose levels are most likely to be elevated.

5. Jerod is experiencing an acute episode of ulcerative colitis. What is the priority for this patient?

• A. Replace lost fluid and sodium.
• B. Monitor for increased serum glucose levels from steroid therapy.
• C. Restrict dietary intake of foods high in potassium.
• D. Note any change in the color and consistency of stools.

Correct answer: A

Rationale: The correct answer is to replace lost fluid and sodium. During an acute episode of ulcerative colitis, the priority is to manage the patient's fluid and electrolyte balance. This is crucial due to the potential for dehydration and electrolyte imbalances resulting from diarrhea and inflammation in the colon. Monitoring serum glucose levels (Choice B) may be important for patients on steroid therapy, but in this scenario, fluid and electrolyte balance take precedence. Restricting dietary intake of foods high in potassium (Choice C) is not a priority in the acute phase of ulcerative colitis. While noting changes in stool color and consistency (Choice D) is important for assessing the patient's gastrointestinal status, it is not the priority when managing acute ulcerative colitis.

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