Nursing Elites

1. When admitting a 64-year-old patient with acute pancreatitis, the healthcare provider should specifically inquire about a history of

• A. diabetes mellitus.
• B. high-protein diet.
• C. cigarette smoking.
• D. alcohol consumption.

Correct answer: D

Rationale: In patients with acute pancreatitis, alcohol consumption is a significant risk factor and one of the most common causes in the United States. It is crucial to assess alcohol intake as it plays a key role in the development of pancreatitis. While cigarette smoking, diabetes mellitus, and high-protein diets can contribute to various health issues, they are not directly associated with the development of acute pancreatitis.

2. A client with a new colostomy is being taught how to care for the colostomy bag. Which statement from the client indicates the need for more education?

• A. I can clean the skin around the ostomy site with soap and water when I change the bag.
• B. I should irrigate the stoma regularly to avoid buildup of gas and odor.
• C. I need to wait 30 minutes after I irrigate to replace the colostomy bag.
• D. I should change the bag when it is one-third to one-fourth full.

Correct answer: C

Rationale: A client with a new colostomy requires education on proper colostomy care. Waiting 30 minutes after irrigating to replace the colostomy bag is unnecessary. The client may reapply the bag once the skin is dry. Cleaning the skin around the ostomy site with soap and water, irrigating the stoma regularly to prevent gas and odor buildup, and changing the bag when it is one-third to one-fourth full are appropriate actions. Therefore, the statement indicating the need for more education is the one suggesting a specific time interval for bag replacement after irrigation.

3. A client has just been diagnosed with active tuberculosis. Which of the following nursing interventions should the nurse perform to prevent transmission to others?

• A. Begin drug therapy within 72 hours of diagnosis
• B. Place the client in a positive-pressure room
• C. Initiate standard precautions
• D. Place the client in a negative-pressure room

Correct answer: D

Rationale: A client diagnosed with active tuberculosis should be placed in isolation in a negative-pressure room to prevent transmission of infection to others. Placing the client in a negative-pressure room ensures that air is exhausted to the outside and received from surrounding areas, preventing tuberculin particles from traveling through the ventilation system and infecting others. Initiating standard precautions, as mentioned in choice C, is essential for infection control but is not specific to preventing transmission in the case of tuberculosis. Beginning drug therapy within 72 hours of diagnosis, as in choice A, is crucial for the treatment of tuberculosis but does not directly address preventing transmission. Placing the client in a positive-pressure room, as in choice B, is incorrect as positive-pressure rooms are used for clients with compromised immune systems to prevent outside pathogens from entering the room, which is not suitable for a client with active tuberculosis.

4. While receiving normal saline infusions to treat a GI bleed, the nurse notes that the patient's lower legs have become edematous and auscultates crackles in the lungs. What should the nurse do first?

• A. Stop the saline infusion immediately
• B. Notify the physician
• C. Elevate the patient's legs
• D. Continue the infusion, as these findings are normal

Correct answer: A

Rationale: The correct answer is to stop the saline infusion immediately. The patient is showing signs of fluid volume overload due to rapid fluid replacement, indicated by lower leg edema and lung crackles. Continuing the infusion could worsen the overload and potentially lead to complications. Notifying the physician is important but should come after stopping the infusion to address the immediate issue. Elevating the patient's legs may help with edema but is not the priority in this situation. Continuing the infusion when the patient is already showing signs of fluid overload is contraindicated and can be harmful.

5. The nurse is caring for a 10-year-old upon admission to the burn unit. One assessment parameter that will indicate that the child has adequate fluid replacement is

• A. Urinary output of 30 ml per hour
• B. No complaints of thirst
• C. Increased hematocrit
• D. Good skin turgor around burn

Correct answer: A

Rationale: The correct answer is urinary output of 30 ml per hour. In a 10-year-old child, this level of urinary output is indicative of adequate fluid replacement without suggesting overload. Monitoring urinary output is crucial in assessing fluid balance. Choices B, C, and D are incorrect. No complaints of thirst do not provide a direct assessment of fluid status. Increased hematocrit is a sign of dehydration, not adequate fluid replacement. Good skin turgor around the burn is a general assessment but may not directly reflect the child's overall fluid status.

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