Nursing Elites

1. 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.

2. A Penrose drain is in place on the first postoperative day following a cholecystectomy. Serosanguineous drainage is noted on the dressing covering the drain. Which nursing intervention is most appropriate?

• A. Notify the physician.
• B. Change the dressing.
• C. Circle the amount on the dressing with a pen.
• D. Continue to monitor the drainage.

Correct answer: B

Rationale: Serosanguineous drainage with a small amount of bile is expected from the Penrose drain for the first 24 hours. Drainage then decreases, and the drain is removed usually within 48 hours. The nurse does not need to notify the physician. A sterile dressing covers the site and should be changed to prevent infection and skin excoriation.

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. The nurse is irrigating a client's colostomy when she complains of abdominal cramping after receiving about 100 mL of the irrigating solution. What should the nurse's first response be in this situation?

• A. Stop the flow of solution temporarily.
• B. Reposition the client on to her right side.
• C. Remove the irrigation tube.
• D. Massage the abdomen gently.

Correct answer: A

Rationale: The abdominal cramping that can occur during colostomy irrigation results from stimulation of the colon by the irrigating solution. The nurse's first response should be to temporarily stop the flow of solution to allow the cramping to subside. Repositioning the client to the right side will not alleviate the cramping. Removing the tube will not decrease the cramping and will necessitate reinsertion of the tube when the irrigation is resumed. Massaging the abdomen gently may be soothing to some clients, but it is not the nurse's first priority action.

5. 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.

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