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. Develop a teaching care plan for Angie who is about to undergo a liver biopsy. Which of the following points do you include?

• A. You’ll need to lie on your stomach during the test.
• B. You’ll need to lie on your right side after the test.
• C. During the biopsy you’ll be asked to exhale deeply and hold it.
• D. The biopsy is performed under general anesthesia.

Correct answer: B

Rationale: Instruct the patient to lie on their right side after the biopsy to apply pressure and prevent bleeding.

3. Kevin has a history of peptic ulcer disease and vomits coffee-ground emesis. What does this indicate?

• A. He has fresh, active upper GI bleeding.
• B. He needs immediate saline gastric lavage.
• C. His gastric bleeding occurred 2 hours earlier.
• D. He needs a transfusion of packed RBCs.

Correct answer: C

Rationale: Coffee-ground emesis is a sign of upper gastrointestinal bleeding that occurred approximately 2 hours earlier. It results from the breakdown of blood in the stomach due to digestive enzymes, giving it a coffee-ground appearance. Choice A is incorrect because coffee-ground emesis indicates older, partially digested blood, not fresh active bleeding. Choice B is incorrect as gastric lavage is not indicated for coffee-ground emesis. Choice D is incorrect because a transfusion of packed RBCs is not the immediate management for this presentation.

4. Which of the following symptoms best describes Murphy’s sign?

• A. Periumbilical ecchymosis exists
• B. On deep palpation and release, pain is elicited
• C. On deep inspiration, pain is elicited and breathing stops
• D. Abdominal muscles are tightened in anticipation of palpation

Correct answer: C

Rationale: Murphy's sign is described as pain elicited on deep inspiration when the examiner's fingers are placed under the right costal margin.

5. A client returns from surgery with a sigmoid colostomy. An ostomy appliance is attached. The priority nursing diagnosis for daily observation and care is:

• A. Diarrhea related to alteration in bowel elimination.
• B. Impaired skin integrity related to seepage.
• C. Impaired nutrition: More than body requirements related to high-fat diet.
• D. Impaired physical mobility related to surgical procedure.

Correct answer: B

Rationale: Impaired skin integrity would be the priority nursing diagnosis for daily care of the colostomy because the effluent from the colostomy can be irritating to the skin. Diarrhea isn't a concern at this point. The client will be allowed nothing by mouth until peristalsis returns. The client should get out of bed on the first postoperative day, so mobility shouldn't be a problem.

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