Nursing Elites

1. When planning care for a client with ulcerative colitis who is experiencing symptoms, which client care activities can the nurse appropriately delegate to a unlicensed assistant?

• A. Assessing the client's bowel sounds
• B. administration of pain medication every 4 hours
• C. Evaluating the client's response to antidiarrheal medications
• D. Maintaining intake and output records

Correct answer: D

Rationale: Delegating tasks such as providing skin care, maintaining intake and output records, and obtaining the client's weight are within the scope of practice for an unlicensed assistant. Assessing bowel sounds and evaluating the response to medications require nursing judgment and should not be delegated.

2. Leigh Ann is receiving pancrelipase (Viokase) for chronic pancreatitis. Which observation best indicates the treatment is effective?

• A. There is no skin breakdown.
• B. Her appetite improves.
• C. She loses more than 10 lbs.
• D. Stools are less fatty and decreased in frequency.

Correct answer: D

Rationale: The effectiveness of pancrelipase (Viokase) for chronic pancreatitis is best indicated by stools being less fatty and decreased in frequency.

3. A client has just had surgery for colon cancer. Which of the following disorders might the client develop?

• A. Peritonitis
• B. Diverticulosis
• C. Partial bowel obstruction
• D. Complete bowel obstruction

Correct answer: C

Rationale: After surgery for colon cancer, the client may develop a partial bowel obstruction.

4. A home care nurse is visiting a client with a diagnosis of pernicious anemia that developed as a result of gastric surgery. The nurse instructs the client that because the stomach lining produces a decreased amount of intrinsic factor in this disorder, the client will need

• A. Vitamin B12 injections.
• B. Vitamin B6 injections.
• C. An antibiotic.
• D. An antacid.

Correct answer: A

Rationale: A lack of the intrinsic factor needed to absorb vitamin B12 occurs in pernicious anemia. Vitamin B12 is needed for the maturation of red blood cells. Vitamin B6 is not necessarily needed for pernicious anemia and can be taken orally. An antibiotic and antacids may be prescribed for certain types of gastric ulcers.

5. The client with cirrhosis has ascites and excess fluid volume. Which measure will the nurse include in the plan of care for this client?

• A. Increase the amount of sodium in the diet.
• B. Limit the amount of fluids consumed.
• C. Encourage frequent ambulation.
• D. Administer magnesium antacids.

Correct answer: B

Rationale: Excess fluid volume, related to the accumulation of fluid in the peritoneal and dependent areas of the body, can occur in the client with cirrhosis. Fluids should be restricted, including fluids given in medications and meals. Sodium restriction also aids in reducing fluid volume excess.

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