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. A client with rectal cancer may exhibit which of the following symptoms?

• A. Abdominal fullness
• B. Gastric fullness
• C. Rectal bleeding
• D. Right upper quadrant pain

Correct answer: C

Rationale: Rectal bleeding is a common symptom in clients with rectal cancer.

3. Your goal is to minimize David’s risk of complications after a heriorrhaphy. You instruct the patient to:

• A. Avoid the use of pain medication.
• B. Cough and deep breathe Q2H.
• C. Splint the incision if he can’t avoid sneezing or coughing.
• D. Apply heat to scrotal swelling.

Correct answer: C

Rationale: Instruct the patient to splint the incision if he can't avoid sneezing or coughing to minimize the risk of complications after heriorrhaphy.

4. You’re caring for Betty with liver cirrhosis. Which of the following assessment findings leads you to suspect hepatic encephalopathy in her?

• A. Asterixis
• B. Chvostek’s sign
• C. Trousseau’s sign
• D. Hepatojugular reflex

Correct answer: A

Rationale: Asterixis, a flapping tremor of the hands, is a sign of hepatic encephalopathy.

5. 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.

Similar Questions