which nursing measure would be most effective in helping the client cough and deep breathe after a cholecystectomy

ATI RN

Gastrointestinal System Nursing Exam Questions

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 nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis. The client is scheduled for surgery for 2 hours. The client begins to complain of increases abdominal pain and begins to vomit. On assessment the nurse notes that the abdomen distended and bowel sounds are diminished. Which of the following is the most appropriate nursing intervention?

A. Administer the prescribed pain medication.
B. Notify the physician.
C. Call and ask the operating room team to perform the surgery as soon as possible.
D. Reposition the client and apply a heating pad on warm setting to the client’s abdomen.

Correct answer: B

Rationale: Based on the signs and symptoms presented in the question, the nurse should suspect peritonitis and should notify the physician. Administering pain medication is not an appropriate intervention. Heat should never be applied to the abdomen of a client with suspected appendicitis. Scheduling surgical time is not within the scope of nursing practice, although the physician probably would perform the surgery earlier than the prescheduled time.

3. A client is providing instructions to a client who is scheduled for an oral cholecystogram. The nurse tells the client to

A. Eat a fat-free meal on the evening before the procedure.
B. Maintain strict NPO status on the day of the procedure.
C. Avoid oral intake except for water on the day of the procedure.
D. Eat a high-fat meal for breakfast on the day of the procedure.

Correct answer: C

Rationale: For an oral cholecystogram, the client should eat a fat-free meal the evening before the procedure and avoid oral intake except for water on the day of the procedure. During the test, the client may be given a high-fat meal or drink to stimulate gallbladder emptying. Choice A is incorrect because the client should have a fat-free meal, not a high-fat meal. Choice B is incorrect as strict NPO status is not required. Choice D is incorrect as a high-fat meal is not recommended for breakfast on the day of the procedure.

4. The nurse is providing discharge instructions to a client following gastrectomy. Which measure will the nurse instruct the client to follow to assist in preventing dumping syndrome?

A. Eat high-carbohydrate foods
B. Limit the fluids taken with meals
C. Ambulate following a meal
D. Sit in a high-Fowlers position during meals

Correct answer: B

Rationale: To prevent dumping syndrome after a gastrectomy, it is recommended to limit fluids taken with meals to slow down gastric emptying and reduce the symptoms.