Nursing Elites

1. Which of the following symptoms would a client in the early stages of peritonitis exhibit?

• A. Abdominal distention
• B. Abdominal pain and rigidity
• C. Hyperactive bowel sounds
• D. Right upper quadrant pain

Correct answer: B

Rationale: In the early stages of peritonitis, the client would exhibit abdominal pain and rigidity due to inflammation.

2. The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750ml of green-brown drainage. Which nursing intervention is most appropriate?

• A. Notify the physician
• B. Document the findings
• C. Irrigate the T-tube
• D. Clamp the T-tube

Correct answer: B

Rationale: Documenting the findings is the most appropriate action as 750ml of green-brown drainage is expected after a cholecystectomy.

3. 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.

4. When a client has peptic ulcer disease, the nurse would expect a priority intervention to be:

• A. Assisting in inserting a Miller-Abbott tube
• B. Assisting in inserting an arterial pressure line
• C. Inserting a nasogastric tube
• D. Inserting an I.V.

Correct answer: C

Rationale: Inserting a nasogastric tube is a priority intervention for a client with peptic ulcer disease to decompress the stomach.

5. Your patient with peritonitis is NPO and complaining of thirst. What is your priority?

• A. Increase the I.V. infusion rate.
• B. Use diversion activities.
• C. Provide frequent mouth care.
• D. Give ice chips every 15 minutes.

Correct answer: C

Rationale: Providing frequent mouth care is the priority for a patient with peritonitis who is NPO and complaining of thirst.

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