Nursing Elites

1. A client with viral hepatitis is discussing with the nurse the need to avoid alcohol and states, 'I’m not sure I can avoid alcohol.' The most appropriate response is

• A. Everything will be alright.
• B. I think you should talk more with the doctor about this.
• C. I don’t believe that.
• D. I’m not sure that I don’t understand. Would you please explain?

Correct answer: D

Rationale: The most appropriate response in this situation is to seek clarification from the client by saying, 'I’m not sure that I don’t understand. Would you please explain?' This response shows empathy and a willingness to listen, encouraging the client to elaborate on their concerns. False reassurance (Choice A) is not helpful as it dismisses the client's feelings. Suggesting to talk more with the doctor (Choice B) may deflect from addressing the client's immediate concerns. Expressing disbelief (Choice C) can create a barrier to open communication, making the client feel unsupported.

2. The client is admitted to the hospital for treatment of acute hepatitis B. Which activity order would the nurse expect to be prescribed?

• A. Bedrest
• B. Encourage ambulation
• C. Out of bed in a chair
• D. No activity restrictions

Correct answer: A

Rationale: Fatigue is a normal response to hepatic cellular damage. During the acute stage, rest is an essential intervention to reduce the metabolic demands on the liver and its blood supply.

3. Which of the following symptoms indicates diverticulosis?

• A. No symptoms exist
• B. Change in bowel habits
• C. Anorexia with low-grade fever
• D. Episodic, dull, or steady midabdominal pain

Correct answer: A

Rationale: Diverticulosis often has no symptoms and is usually found incidentally during tests for other conditions.

4. 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.

5. The nurse is teaching the client how to perform a colostomy irrigation. To enhance the effectiveness of the irrigation and fecal returns, what measure should the nurse instruct the client to do?

• A. Increase fluid intake
• B. Reduce the amount of irrigation solution
• C. Perform the irrigation in the evening
• D. Place heat on the abdomen

Correct answer: A

Rationale: Increasing fluid intake helps to enhance the effectiveness of colostomy irrigation by softening the stool and promoting better fecal return.

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