Nursing Elites

1. A client with liver dysfunction has low serum levels of thrombin. The nurse provides care, anticipating that this client is most at risk of

• A. Dehydration
• B. Malnutrition
• C. Bleeding
• D. Infection

Correct answer: C

Rationale: Thrombin is produced by the liver and is necessary for normal clotting. When a client with liver dysfunction has low serum levels of thrombin, they are at risk of bleeding due to impaired clotting mechanisms. Dehydration (choice A) is not directly related to low thrombin levels. Malnutrition (choice B) may impact overall health but is not the most immediate concern associated with low thrombin levels. Infection (choice D) is not directly related to the clotting function affected by low thrombin levels.

2. After abdominal surgery, your patient has a severe coughing episode that causes wound evisceration. In addition to calling the doctor, which intervention is most appropriate?

• A. Irrigate the wound & organs with Betadine.
• B. Cover the wound with a saline soaked sterile dressing.
• C. Apply a dry sterile dressing & binder.
• D. Push the organs back & cover with moist sterile dressings.

Correct answer: B

Rationale: Covering the wound with a saline soaked sterile dressing is the most appropriate intervention for wound evisceration.

3. 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.

4. A client is admitted to the hospital with acute viral hepatitis. Which of the following signs or symptoms would the nurse expect to note based on this diagnosis?

• A. Spider angiomas
• B. Fatigue
• C. Pale urine
• D. Weight gain

Correct answer: B

Rationale: Common signs of acute viral hepatitis include weight loss, dark urine, and fatigue. The client is anorexic, possibly from a toxin produced by the diseased liver, and finds food distasteful. The urine darkens because of excess bilirubin being excreted by the kidneys. Fatigue occurs during all phases of hepatitis.

5. 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.

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