Nursing Elites

1. 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.

2. The client being treated for esophageal varices has a Sengstaken-Blakemore tube inserted to control the bleeding. The most important assessment is for the nurse to:

• A. Check that the hemostat is on the bedside
• B. Monitor IV fluids for the shift
• C. Regularly assess respiratory status
• D. Check that the balloon is deflated on a regular basis

Correct answer: C

Rationale: Regularly assessing respiratory status is crucial when a Sengstaken-Blakemore tube is inserted to control bleeding in esophageal varices.

3. Which of the following aspects is the priority focus of nursing management for a client with peritonitis?

• A. Fluid and electrolyte balance
• B. Gastric irrigation
• C. Pain management
• D. Psychosocial issues

Correct answer: A

Rationale: The priority focus of nursing management for a client with peritonitis is fluid and electrolyte balance to prevent shock.

4. 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.

5. A patient who underwent abdominal surgery now has a gaping incision due to delayed wound healing. Which method is correct when you irrigate a gaping abdominal incision with sterile normal saline solution, using a piston syringe?

• A. Rapidly instill a stream of irrigating solution into the wound.
• B. Apply a wet-to-dry dressing to the wound after the irrigation.
• C. Moisten the area around the wound with normal saline solution after the irrigation.
• D. Irrigate continuously until the solution becomes clear or all of the solution is used.

Correct answer: D

Rationale: Irrigating continuously until the solution becomes clear or all of the solution is used is the correct method when irrigating a gaping abdominal incision.

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