Nursing Elites

1. The nurse would assess the client experiencing an acute episode of cholecystitis for pain that is located in the right:

• A. Upper quadrant and radiates to the left scapula and shoulder
• B. Upper quadrant and radiates to the right scapula and shoulder
• C. Lower quadrant and radiates to the umbilicus
• D. Lower quadrant and radiates to the back

Correct answer: B

Rationale: Pain from cholecystitis is typically located in the right upper quadrant and may radiate to the right scapula and shoulder.

2. 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.

3. Your patient, Christopher, has a diagnosis of ulcerative colitis and has severe abdominal pain aggravated by movement, rebound tenderness, fever, nausea, and decreased urine output. This may indicate which complication?

• A. Fistula.
• B. Bowel perforation.
• C. Bowel obstruction.
• D. Abscess.

Correct answer: B

Rationale: Severe abdominal pain aggravated by movement, rebound tenderness, fever, nausea, and decreased urine output in a patient with ulcerative colitis may indicate bowel perforation.

4. Which of the following symptoms best describes Murphy’s sign?

• A. Periumbilical ecchymosis exists
• B. On deep palpation and release, pain is elicited
• C. On deep inspiration, pain is elicited and breathing stops
• D. Abdominal muscles are tightened in anticipation of palpation

Correct answer: C

Rationale: Murphy's sign is described as pain elicited on deep inspiration when the examiner's fingers are placed under the right costal margin.

5. Which of the following nursing measures would be inappropriate when caring for a client with a Cantor tube?

• A. Injecting 10 mL of air into the tube to facilitate drainage.
• B. Applying a water-soluble lubricant to the client's nares.
• C. Coiling extra tubing on the client's bed.
• D. Irrigating the tube with 50 mL of normal saline solution.

Correct answer: D

Rationale: Intestinal tubes are not irrigated. Injecting air into the tube, applying water-soluble lubricant, and coiling extra tubing are appropriate nursing measures.

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