Nursing Elites

1. 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.

2. You’re caring for Jane, a 57 y.o. patient with liver cirrhosis who develops ascites and requires paracentesis. Before her paracentesis, you instruct her to:

• A. Empty her bladder.
• B. Lie supine in bed.
• C. Remain NPO for 4 hours.
• D. Clean her bowels with an enema.

Correct answer: A

Rationale: Before paracentesis, instruct the patient to empty her bladder to avoid bladder injury during the procedure.

3. Matt is a 49 y.o. with a hiatal hernia that you are about to counsel. Health care counseling for Matt should include which of the following instructions?

• A. Restrict intake of high-carbohydrate foods.
• B. Increase fluid intake with meals.
• C. Increase fat intake.
• D. Eat three regular meals a day.

Correct answer: D

Rationale: For a patient with a hiatal hernia, it is important to eat three regular meals a day to prevent symptoms.

4. George has a T tube in place after gallbladder surgery. Before discharge, what information or instructions should be given regarding the T tube drainage?

• A. If there is any drainage, notify the surgeon immediately.
• B. The drainage will decrease daily until the bile duct heals.
• C. First, the drainage is dark green; then it becomes dark yellow.
• D. If the drainage stops, milk the tube toward the puncture wound.

Correct answer: B

Rationale: Before discharge, inform the patient that the drainage will decrease daily until the bile duct heals.

5. A nurse is assigned to a 40-year-old client who has a diagnosis of chronic pancreatitis. The nurse reviews the laboratory result, anticipating a laboratory report that indicates a serum amylase level of

• A. 45 units/L
• B. 100 units/L
• C. 300 units/L
• D. 500 units/L

Correct answer: C

Rationale: The normal serum amylase level is 25 to 151 IU/L. With chronic cases of pancreatitis, the rise in serum amylase levels usually does not exceed three times the normal value. In acute pancreatitis, the value may exceed five times the normal value. Options 1 and 2 are within normal limits. Option 3 is an extremely elevated level seen in acute pancreatitis.

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