Nursing Elites

1. 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.

2. Which of the following nursing measures would be inappropriate when caring for a client with a Cantor tube?

• A. Injecting 10 mL of air into the tube to facilitate drainage.
• B. Applying a water-soluble lubricant to the client's nares.
• C. Coiling extra tubing on the client's bed.
• D. Irrigating the tube with 50 mL of normal saline solution.

Correct answer: D

Rationale: Intestinal tubes are not irrigated. Injecting air into the tube, applying water-soluble lubricant, and coiling extra tubing are appropriate nursing measures.

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. A female client complains of gnawing epigastric pain for a few hours after meals. At times, when the pain is severe, vomiting occurs. Specific tests are indicated to rule out:

• A. Cancer of the stomach
• B. Peptic ulcer disease
• C. Chronic gastritis
• D. Pylorospasm

Correct answer: A

Rationale: Specific tests are indicated to rule out cancer of the stomach when a client complains of gnawing epigastric pain and vomiting after meals.

5. The nurse is monitoring a client for the early signs of dumping syndrome. Which symptom indicates this occurrence?

• A. Abdominal cramping and pain
• B. Bradycardia and indigestion
• C. Sweating and pallor
• D. Double vision and chest pain

Correct answer: C

Rationale: Sweating and pallor are early signs of dumping syndrome, a condition where food moves too quickly from the stomach to the small intestine.

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