Nursing Elites

1. Your patient with peritonitis is NPO and complaining of thirst. What is your priority?

• A. Increase the I.V. infusion rate.
• B. Use diversion activities.
• C. Provide frequent mouth care.
• D. Give ice chips every 15 minutes.

Correct answer: C

Rationale: The correct answer is C: Provide frequent mouth care. In a patient with peritonitis who is NPO and thirsty, the priority is to maintain oral hygiene and provide comfort by moistening the mouth with frequent mouth care. This helps alleviate the sensation of thirst and maintains oral health. Increasing the IV infusion rate (choice A) may not address the patient's discomfort directly related to thirst. Using diversion activities (choice B) is not as critical as addressing the patient's immediate need for oral care. Giving ice chips every 15 minutes (choice D) is not recommended for a patient with peritonitis who is NPO, as it can lead to complications or worsen the condition.

2. The nurse has given instructions to the client with an ileostomy about foods to eat to thicken the stool. The nurse determines that the client needs further instructions if the client stated to eat which of the following foods to make the stools less watery?

• A. Pasta
• B. Boiled rice
• C. Bran
• D. Low-fat cheese

Correct answer: C

Rationale: Bran is high in fiber and should not be consumed to thicken the stool as it will make the stools more watery.

3. You’re caring for Carin who has just had ileostomy surgery. During the first 24 hours post-op, how much drainage can you expect from the ileostomy?

• A. 100 ml
• B. 500 ml
• C. 1500 ml
• D. 5000 ml

Correct answer: C

Rationale: During the first 24 hours post-op, you can expect about 1500 ml of drainage from the ileostomy.

4. 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.

5. The client with peptic ulcer disease is scheduled for a pyloroplasty. The client asks the nurse about the procedure. The nurse plans to respond knowing that a pyloroplasty involves:

• A. Cutting the vagus nerve
• B. Removing the distal portion of the stomach
• C. Removal of the ulcer and a large portion of the cells that produce hydrochloric acid
• D. An incision and resuturing of the pylorus to relax the muscle and enlarge the opening from the stomach to the duodenum.

Correct answer: D

Rationale: A pyloroplasty involves making an incision in the pylorus (the opening from the stomach to the duodenum) and then resuturing it to relax the muscle and enlarge the opening.

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