Nursing Elites

1. Which nursing measure would be most effective in helping the client cough and deep breathe after a cholecystectomy?

• A. Having the client take rapid, shallow breaths to decrease pain.
• B. Having the client lay on the left side while coughing and deep breathing.
• C. Teaching the client to use a folded blanket or pillow to splint the incision.
• D. Withholding pain medication so the client can be alert enough to follow the nurse's instructions.

Correct answer: C

Rationale: After a cholecystectomy, teaching the client to use a folded blanket or pillow to splint the incision will be most effective in helping the client cough and deep breathe. This technique provides support and reduces pain during coughing and deep breathing, promoting better lung expansion. Having the client take rapid, shallow breaths would not be effective in decreasing pain; instead, deep breathing is encouraged to prevent complications like atelectasis. Lying on the left side would limit lung expansion; therefore, the client should be positioned in semi-Fowler's or Fowler's position to maximize lung expansion. Withholding pain medication can lead to discomfort and reluctance to cough and deep breathe, hindering recovery.

2. The client with a colostomy has an order for irrigation of the colostomy. The nurse uses which solution for the irrigation?

• A. Distilled water
• B. Tap water
• C. Sterile water
• D. Lactated Ringer’s

Correct answer: B

Rationale: The correct solution to use for the irrigation of a colostomy is warm tap water or saline solution. If tap water is not suitable for drinking, bottled water can be used. Distilled water, sterile water, and Lactated Ringer’s are not appropriate solutions for colostomy irrigation. Distilled water lacks essential minerals, sterile water may not provide adequate cleaning, and Lactated Ringer’s is not indicated for this procedure.

3. Which of the following laboratory results would be expected in a client with peritonitis?

• A. Partial thromboplastin time above 100 seconds
• B. Hemoglobin level below 10 mg/dL
• C. Potassium level above 5.5 mEq/L
• D. White blood cell count above 15,000

Correct answer: D

Rationale: A white blood cell count above 15,000 is indicative of an infection, such as peritonitis.

4. The nurse is planning to teach the client with gastroesophageal reflux disease about substances that will increase the lower esophageal sphincter pressure. Which of the following items would the nurse include on this list?

• A. Fatty foods
• B. Nonfat milk
• C. Chocolate
• D. Coffee

Correct answer: B

Rationale: Foods that increase the lower esophageal sphincter (LES) pressure will decrease reflux, and lessen the symptoms of gastroesophageal reflux disease (GERD). The food substance that will increase the LES pressure is nonfat milk. The other substances listed decrease the LES pressure, thus increasing reflux symptoms. Aggravating substances include chocolate, coffee, fatty foods and alcohol.

5. The nurse is monitoring a client for the early signs of dumping syndrome. Which symptom indicates this occurrence?

• A. Abdominal cramping and pain
• B. Bradycardia and indigestion
• C. Sweating and pallor
• D. Double vision and chest pain

Correct answer: C

Rationale: Sweating and pallor are early signs of dumping syndrome, a condition where food moves too quickly from the stomach to the small intestine.

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