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. Which of the following types of diets is implicated in the development of diverticulosis?

• A. Low-fiber diet
• B. High-fiber diet
• C. High-protein diet
• D. Low-carbohydrate diet

Correct answer: A

Rationale: A low-fiber diet is implicated in the development of diverticulosis because it leads to harder stools and increased pressure in the colon. The lack of fiber results in decreased bulk and slower transit time, predisposing individuals to constipation and the formation of diverticula. High-fiber diets, on the other hand, promote regular bowel movements and help prevent diverticular disease. High-protein and low-carbohydrate diets do not have a direct association with diverticulosis.

3. Which of the following conditions is most likely to directly cause peritonitis?

• A. Cholelithiasis
• B. Gastritis
• C. Perforated ulcer
• D. Incarcerated hernia

Correct answer: C

Rationale: A perforated ulcer is most likely to directly cause peritonitis due to the leakage of gastric contents into the peritoneal cavity.

4. Of the following signs and symptoms of bowel obstruction, which is related primarily to small bowel obstruction rather than large bowel obstruction?

• A. Profuse vomiting.
• B. Cramping abdominal pain.
• C. Abdominal distention.
• D. High-pitched bowel sounds above the obstruction.

Correct answer: A

Rationale: Profuse vomiting is the classic sign of small bowel obstruction and rarely occurs with large bowel obstruction. Abdominal discomfort and distention are present in both small and large bowel obstructions, but distention is more common in large bowel obstruction. High-pitched bowel sounds indicate hyperperistalsis, which occurs early in obstruction.

5. 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.

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