Nursing Elites

1. Stephen is a 62 y.o. patient that has had a liver biopsy. Which of the following groups of signs alert you to a possible pneumothorax?

• A. Dyspnea and reduced or absent breath sounds over the right lung
• B. Tachycardia, hypotension, and cool, clammy skin
• C. Fever, rebound tenderness, and abdominal rigidity
• D. Redness, warmth, and drainage at the biopsy site

Correct answer: A

Rationale: Dyspnea and reduced or absent breath sounds over the right lung are signs of a possible pneumothorax.

2. The nurse is caring for a client with chronic gastritis. The nurse monitors the client, knowing that this client is at risk for which of the following vitamin deficiencies?

• A. Vitamin A
• B. Vitamin B12
• C. Vitamin C
• D. Vitamin E

Correct answer: B

Rationale: Clients with chronic gastritis are at risk for Vitamin B12 deficiency due to impaired absorption.

3. Before bowel surgery, Lee is to administer enemas until clear. During administration, he complains of intestinal cramps. What do you do next?

• A. Discontinue the procedure.
• B. Lower the height of the enema container.
• C. Complete the procedure as quickly as possible.
• D. Continue administration of the enema as ordered without making any adjustments.

Correct answer: B

Rationale: If a patient complains of intestinal cramps during an enema, lowering the height of the enema container can help reduce discomfort.

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 performing a colostomy irrigation on a client. During the irrigation, a client begins to complain of abdominal cramps. Which of the following is the most appropriate nursing action?

• A. Notify the physician
• B. Increase the height of the irrigation
• C. Stop the irrigation temporarily.
• D. Medicate with dilaudid and resume the irrigation

Correct answer: C

Rationale: If a client experiences abdominal cramps during a colostomy irrigation, it is appropriate to stop the irrigation temporarily to allow the cramps to subside.

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