Nursing Elites

1. 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.

2. A client with liver dysfunction is having difficulty with protein metabolism. The nurse anticipates that the results of which of the following serum laboratory studies will be elevated?

• A. Lactic acid
• B. Ammonia
• C. Albumin
• D. Lactase

Correct answer: B

Rationale: During deamination of proteins, the liver splits the amino group from the carbon-containing compound, which results in the formation of ammonia and a carbon residue. The liver then converts the toxic ammonia substance into urea, which can be excreted by the kidneys. Clients with liver dysfunction may have high serum ammonia levels as a result.

3. A client with peptic ulcer disease tells the nurse that he has black stools, which he has not reported to his physician. Based on this information, which nursing diagnosis would be appropriate for this client?

• A. Ineffective coping related to fear of diagnosis of chronic illness
• B. Deficient knowledge related to unfamiliarity with significant signs and symptoms
• C. Constipation related to decreased gastric motility
• D. Imbalanced nutrition: Less than body requirements due to gastric bleeding

Correct answer: B

Rationale: Deficient knowledge related to unfamiliarity with significant signs and symptoms is appropriate because the client did not report the black stools, which can be a sign of bleeding.

4. 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.

5. A client has a percutaneous endoscopic gastrostomy tube inserted for tube feedings. Before starting a continuous feeding, the nurse should place the client in which position?

• A. Semi-Fowlers
• B. Supine
• C. Reverse Trendelenburg
• D. High Fowler’s

Correct answer: D

Rationale: Placing the client in a high Fowler’s position helps prevent aspiration and promotes proper digestion and feeding tube function.

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