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 definitions best describes diverticulosis?

• A. An inflamed outpouching of the intestine
• B. A noninflamed outpouching of the intestine
• C. The partial impairment of the forward flow of intestinal contents
• D. An abnormal protrusion of an organ through the structure that usually holds it

Correct answer: B

Rationale: The correct answer is B: 'A noninflamed outpouching of the intestine.' Diverticulosis refers to the presence of small, bulging pouches (diverticula) that can form in the lining of the digestive system, especially the colon. These pouches are typically noninflamed. Choice A is incorrect because it describes diverticulitis, which is the inflammation of these pouches. Choice C is incorrect as it defines bowel obstruction, not diverticulosis. Choice D is incorrect as it refers to a hernia, not diverticulosis.

3. A nurse is reviewing the results of serum laboratory studies drawn on a client who is suspected of having hepatitis. The nurse interprets that an elevation in which of the following studies is the most specific indicator of the disease?

• A. Erythrocyte sedimentation rate
• B. Serum bilirubin
• C. Hemoglobin
• D. Blood urea nitrogen

Correct answer: C

Rationale: Laboratory indicators of hepatitis include elevated liver enzymes, serum bilirubin level, and erythrocyte sedimentation rate is nonspecific test that indicates the presence of inflammation somewhere in the body. Elevated blood urea nitrogen may indicate renal dysfunction. A hemoglobin level is unrelated to this diagnosis.

4. Claire, a 33 y.o. is on your floor with a possible bowel obstruction. Which intervention is priority for her?

• A. Obtain daily weights.
• B. Measure abdominal girth.
• C. Keep strict intake and output.
• D. Encourage her to increase fluids.

Correct answer: B

Rationale: For a patient with a possible bowel obstruction, measuring abdominal girth is a priority to monitor for signs of worsening obstruction or distention.

5. Which of the following dietary measures would be useful in preventing esophageal reflux?

• A. Eating small, frequent meals
• B. Increasing fluid intake
• C. Avoiding air swallowing with meals
• D. Adding a bedtime snack to the dietary plan

Correct answer: A

Rationale: Eating small, frequent meals helps prevent esophageal reflux.

Similar Questions