Nursing Elites

1. When preparing the client with hepatitis A for extended convalescence, the nurse teaches the client about problems that may occur. The nurse knows that the client has understood the teaching when he says that he is most likely to have difficulty:

• A. Controlling abdominal pain.
• B. Maintaining a regular bowel elimination pattern.
• C. Preventing respiratory complications.
• D. Maintaining a positive, optimistic outlook.

Correct answer: D

Rationale: Convalescence after hepatitis A may take weeks or even months. Boredom and depression are common problems that the client should anticipate. Abdominal pain is not usually a symptom of hepatitis A. Maintaining a regular bowel elimination pattern is not usually a problem with hepatitis. Problems preventing respiratory complications are unlikely. To support healing, activity is strictly limited but bed rest is not prescribed.

2. When teaching an elderly client how to prevent constipation, which of the following instructions should the nurse include?

• A. Drink 6 glasses of fluid each day.
• B. Avoid grain products and nuts.
• C. Add at least 4 grams of brain to your cereal each morning.
• D. Be sure to get regular exercise.

Correct answer: D

Rationale: To prevent constipation, elderly clients should be encouraged to get regular exercise, which promotes bowel motility.

3. Gail is scheduled for a cholecystectomy. After completion of preoperative teaching, Gail states,”If I lie still and avoid turning after the operation, I’ll avoid pain. Do you think this is a good idea?” What is the best response?

• A. You’ll need to turn from side to side every 2 hours.
• B. It’s always a good idea to rest quietly after surgery.
• C. The doctor will probably order you to lie flat for 24 hours.
• D. Why don’t you decide about activity after you return from the recovery room?

Correct answer: A

Rationale: The best response to Gail is to inform her that she will need to turn from side to side every 2 hours to prevent complications.

4. You’re doing preoperative teaching with Gertrude who has ulcerative colitis who needs surgery to create an ileoanal reservoir. Which information do you include?

• A. A reservoir is created that exits through the abdominal wall.
• B. A second surgery is required 12 months after the first surgery.
• C. A permanent ileostomy is created.
• D. The surgery occurs in two stages.

Correct answer: D

Rationale: The surgery to create an ileoanal reservoir occurs in two stages.

5. The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750ml of green-brown drainage. Which nursing intervention is most appropriate?

• A. Notify the physician
• B. Document the findings
• C. Irrigate the T-tube
• D. Clamp the T-tube

Correct answer: B

Rationale: Documenting the findings is the most appropriate action as 750ml of green-brown drainage is expected after a cholecystectomy.

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