which nursing measure would be most effective in helping the client cough and deep breathe after a cholecystectomy
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Nursing Elites

ATI RN

Gastrointestinal System Nursing Exam Questions

1. Which nursing measure would be most effective in helping the client cough and deep breathe after a cholecystectomy?

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.

2. Rob is a 46 y.o. admitted to the hospital with a suspected diagnosis of Hepatitis B. He’s jaundiced and reports weakness. Which intervention will you include in his care?

Correct answer: D

Rationale: For a patient with hepatitis B who is jaundiced and reports weakness, providing rest periods after small, frequent meals is important.

3. Cholestyramine resin (Questran Light) is prescribed for the client with an elevated serum cholesterol level. The nurse would instruct the client to take the medication

Correct answer: B

Rationale: Cholestyramine resin binds with bile salts in the intestines to form a compound that is excreted in the feces. The client should be instructed to mix the medication with 3 to 6 oz of water, milk, fruit juice, or soup. The medication should be administered before meals. The medication is not administered via rectal suppository.

4. A Penrose drain is in place on the first postoperative day following a cholecystectomy. Serosanguineous drainage is noted on the dressing covering the drain. Which nursing intervention is most appropriate?

Correct answer: B

Rationale: Serosanguineous drainage with a small amount of bile is expected from the Penrose drain for the first 24 hours. Drainage then decreases, and the drain is removed usually within 48 hours. The nurse does not need to notify the physician. A sterile dressing covers the site and should be changed to prevent infection and skin excoriation.

5. A client with gastric cancer may exhibit which of the following symptoms?

Correct answer: C

Rationale: Clients with gastric cancer may experience a feeling of fullness due to the presence of the tumor.

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