Nursing Elites

1. While caring for a client with peptic ulcer disease, the client reports that he has been nauseated most of the day and is now feeling lightheaded and dizzy. Based upon these findings, which nursing actions would be most appropriate for the nurse to take?

• A. Administering an antacid hourly until nausea subsides.
• B. Monitoring the client's vital signs
• C. Notifying the family and friends of the client's symptoms
• D. Initiating oxygen therapy

Correct answer: B

Rationale: Monitoring the client's vital signs and notifying the physician of the client's symptoms are crucial actions based on the reported symptoms.

2. A client who has ulcerative colitis has persistent diarrhea. He is thin and has lost 12 pounds since the exacerbation of his ulcerative colitis. The nurse should anticipate that the physician will order which of the following treatment approaches to help the client meet his nutritional needs?

• A. Initiate continuous enteral feedings
• B. Encourage a high protein, high-calorie diet
• C. Implement total parenteral nutrition
• D. Provide six small meals a day.

Correct answer: C

Rationale: Implementing total parenteral nutrition helps meet the nutritional needs of a client with persistent diarrhea and significant weight loss due to ulcerative colitis.

3. You’re caring for Betty with liver cirrhosis. Which of the following assessment findings leads you to suspect hepatic encephalopathy in her?

• A. Asterixis
• B. Chvostek’s sign
• C. Trousseau’s sign
• D. Hepatojugular reflex

Correct answer: A

Rationale: Asterixis, a flapping tremor of the hands, is a sign of hepatic encephalopathy.

4. The nurse is preparing a discharge teaching plan for the client who had an umbilical hernia repair. Which of the following would the nurse include in the plan?

• A. Restricting pain medication
• B. Maintaining bedrest
• C. Avoiding coughing
• D. Irrigating the drain

Correct answer: C

Rationale: Bedrest is not required following this surgical procedure. The client should take analgesics as needed and as prescribed to control pain. A drain is not used in this surgical procedure, although the client may be instructed in simple dressing changes. Coughing is avoided to prevent disruption of the tissue integrity, which can occur because of the location of this surgical procedure.

5. A Penrose drain is in place on the first postoperative day following a cholecystectomy. Serosanguineous drainage is noted on the dressing covering the drain. Which nursing intervention is most appropriate?

• A. Notify the physician.
• B. Change the dressing.
• C. Circle the amount on the dressing with a pen.
• D. Continue to monitor the drainage.

Correct answer: B

Rationale: Serosanguineous drainage with a small amount of bile is expected from the Penrose drain for the first 24 hours. Drainage then decreases, and the drain is removed usually within 48 hours. The nurse does not need to notify the physician. A sterile dressing covers the site and should be changed to prevent infection and skin excoriation.

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