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 patient who underwent abdominal surgery now has a gaping incision due to delayed wound healing. Which method is correct when you irrigate a gaping abdominal incision with sterile normal saline solution, using a piston syringe?

• A. Rapidly instill a stream of irrigating solution into the wound.
• B. Apply a wet-to-dry dressing to the wound after the irrigation.
• C. Moisten the area around the wound with normal saline solution after the irrigation.
• D. Irrigate continuously until the solution becomes clear or all of the solution is used.

Correct answer: D

Rationale: Irrigating continuously until the solution becomes clear or all of the solution is used is the correct method when irrigating a gaping abdominal incision.

3. Regina is a 46 y.o. woman with ulcerative colitis. You expect her stools to look like:

• A. Watery and frothy.
• B. Bloody and mucoid.
• C. Firm and well-formed.
• D. Alternating constipation and diarrhea.

Correct answer: B

Rationale: Stools in ulcerative colitis are typically bloody and mucoid.

4. During an abdominal assessment, a nurse finds pulsation between the umbilicus and pubis on a client. What finding should be reported to the physician?

• A. Concave, midline umbilicus
• B. Pulsation between the umbilicus and pubis
• C. Bowel sound frequency of 15 sounds per minute
• D. Absence of a bruit

Correct answer: B

Rationale: The presence of pulsation between the umbilicus and pubis could indicate an abdominal aortic aneurysm, which is a serious condition and should be reported to the physician promptly. A concave, midline umbilicus is a normal finding. Bowel sound frequency can vary widely and is not a cause for concern at 15 sounds per minute. Absence of a bruit is a normal finding in an abdominal assessment and does not require reporting.

5. A 53 y.o. patient has undergone a partial gastrectomy for adenocarcinoma of the stomach. An NG tube is in place and is connected to low continuous suction. During the immediate postoperative period, you expect the gastric secretions to be which color?

• A. Brown.
• B. Clear.
• C. Red.
• D. Yellow.

Correct answer: C

Rationale: During the immediate postoperative period after a partial gastrectomy, gastric secretions are expected to be red.

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