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 female client complains of gnawing epigastric pain for a few hours after meals. At times, when the pain is severe, vomiting occurs. Specific tests are indicated to rule out:

• A. Cancer of the stomach
• B. Peptic ulcer disease
• C. Chronic gastritis
• D. Pylorospasm

Correct answer: A

Rationale: Specific tests are indicated to rule out cancer of the stomach when a client complains of gnawing epigastric pain and vomiting after meals.

3. When teaching a community group about measures to prevent colon cancer, which instruction should the nurse include?

• A. Limit fat intake to 20% to 25% of your total daily calories.
• B. Include 15 to 20 grams of fiber into your daily diet.
• C. Get an annual rectal examination after age 35.
• D. Undergo sigmoidoscopy annually after age 50.

Correct answer: A

Rationale: Limiting fat intake is a recommended measure to reduce the risk of colon cancer. Including fiber, undergoing annual rectal examinations, and sigmoidoscopy are also important, but limiting fat intake is directly related to reducing cancer risk.

4. Dark, tarry stools indicate bleeding in which location of the GI tract?

• A. Upper colon.
• B. Lower colon.
• C. Upper GI tract.
• D. Small intestine.

Correct answer: C

Rationale: Dark, tarry stools indicate bleeding in the upper GI tract.

5. A client with ulcerative colitis is diagnosed with a mild case of the disease. The nurse doing dietary teaching gives the client examples of foods to eat that represent which of the following therapeutic diets?

• A. High-fat with milk
• B. High-protein without milk
• C. Low-roughage without milk
• D. Low-roughage with milk

Correct answer: C

Rationale: The client with a mild case of ulcerative colitis is often advised to follow a diet low in roughage and avoid milk. This dietary approach helps reduce the frequency of diarrhea in these clients. Therefore, the correct therapeutic diet for the client with ulcerative colitis in this scenario is a low-roughage diet without milk. Choices A, B, and D are incorrect because high-fat, high-protein, and low-roughage with milk diets are not typically recommended for clients with ulcerative colitis, especially those with mild cases.

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