Nursing Elites

1. A client with viral hepatitis has no appetite, and food makes the client nauseated. Which of the following interventions would be most appropriate?

• A. Explain that high-fat diets usually are tolerated better.
• B. Encourage intake of foods high in protein.
• C. Explain that the majority of calories need to be consumed in the evening hours.
• D. Monitor for fluid and electrolyte imbalance.

Correct answer: D

Rationale: If nausea occurs and persists, the client will need to be assessed for fluid and electrolyte imbalance. Explaining to the client that the majority of calories should be eaten in the morning hours is important because nausea occurs most often in the afternoon and evening. Clients should select a diet high in calories because energy is required for healing. Protein increases the workload on the liver. Changes in bilirubin interfere with fat absorption, so low-fat diets are tolerated better.

2. A nurse has been caring for a client with a Sengstaken-Blakemore tube. The physician arrives on the nursing unit and deflates the esophageal balloon. The nurse should monitor the client most closely for which of the following?

• A. Swelling of the abdomen
• B. Bloody diarrhea
• C. Vomiting blood
• D. An elevated temperature and arise in blood pressure

Correct answer: C

Rationale: A Sengstaken-Blakemore tube is inserted into a client with a diagnosis of cirrhosis and ruptured esophageal varices. The tube has an esophageal and a gastric balloon. The esophageal balloon exerts pressure on the bleeding. The pressure of the esophageal balloon is released at intervals to decrease the risk of trauma to esophageal tissues, including esophageal rupture or necrosis. When the balloon is deflated the client may begin to bleed again from the esophageal varices, noted by vomiting of blood.

3. The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750ml of green-brown drainage. Which nursing intervention is most appropriate?

• A. Notify the physician
• B. Document the findings
• C. Irrigate the T-tube
• D. Clamp the T-tube

Correct answer: B

Rationale: Documenting the findings is the most appropriate action as 750ml of green-brown drainage is expected after a cholecystectomy.

4. After an abdominal resection for colon cancer, Madeline returns to her room with a Jackson-Pratt drain in place. The purpose of the drain is to:

• A. Irrigate the incision with a saline solution.
• B. Prevent bacterial infection of the incision.
• C. Measure the amount of fluid lost after surgery.
• D. Prevent accumulation of drainage in the wound.

Correct answer: D

Rationale: The purpose of the Jackson-Pratt drain is to prevent the accumulation of drainage in the wound after an abdominal resection.

5. After a subtotal gastrectomy, the nurse should anticipate that nasogastric tube drainage will be what color for about 12 to 24 hours after surgery?

• A. Dark brown
• B. Bile green
• C. Bright red
• D. Cloudy white

Correct answer: A

Rationale: Dark brown drainage is expected for about 12 to 24 hours after surgery.

Similar Questions