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

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.

3. A client is recovering from an ileostomy that was performed to treat inflammatory bowel disease. During discharge teaching for this client, the nurse should stress:

Correct answer: A

Rationale: The correct answer is A: increasing fluid intake to prevent dehydration. An ileostomy typically drains liquid waste, so the client is at risk of fluid loss. By increasing fluid intake, the client can prevent dehydration. It's essential for the client to wear a collection appliance at all times because ileostomy drainage is incontinent. Consuming a low-protein, high-fiber diet is not recommended as high-fiber foods can cause intestinal irritation. Enteric-coated medications should be avoided because they may not be absorbed properly after an ileostomy.

4. After abdominal surgery, your patient has a severe coughing episode that causes wound evisceration. In addition to calling the doctor, which intervention is most appropriate?

Correct answer: B

Rationale: Covering the wound with a saline soaked sterile dressing is the most appropriate intervention for wound evisceration.

5. The pain of a duodenal ulcer can be distinguished from that of a gastric ulcer by which of the following characteristics?

Correct answer: D

Rationale: Pain on an empty stomach is characteristic of a duodenal ulcer, while pain on eating is characteristic of a gastric ulcer.

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