Nokea
The nurse recognizes that teaching a 44-year-old woman following a laparoscopic cholecystectomy has been effective when the patient states which of the following?
- A. I can expect yellow-green drainage from the incision for a few days.
- B. I can remove the bandages on my incisions tomorrow and take a shower.
- C. I should plan to limit my activities and not return to work for 4 to 6 weeks.
- D. I will always need to maintain a low-fat diet since I no longer have a gallbladder.
Correct Answer: B
Rationale: The correct answer is, 'I can remove the bandages on my incisions tomorrow and take a shower.' After a laparoscopic cholecystectomy, patients have Band-Aids over the incisions and can typically remove the bandages the next day. Patients are usually discharged the same or next day and have minimal restrictions on their daily activities. Yellow-green drainage from the incision would be abnormal, requiring the patient to contact their healthcare provider. While a low-fat diet may be recommended initially after surgery, it is not a lifelong requirement, as the body can adjust to the absence of the gallbladder over time. Choice A is incorrect as abnormal drainage should be reported. Choice C is incorrect as most patients can resume normal activities within a few days to a week. Choice D is incorrect as maintaining a low-fat diet is not a lifelong necessity after a cholecystectomy.
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Which topic is most important to include in patient teaching for a 41-year-old patient diagnosed with early alcoholic cirrhosis?
- A. Maintaining good nutrition
- B. Avoiding alcohol ingestion
- C. Taking lactulose (Cephulac)
- D. Using vitamin B supplements
Correct Answer: B
Rationale: The most important topic to include in patient teaching for a 41-year-old patient diagnosed with early alcoholic cirrhosis is avoiding alcohol ingestion. Alcohol abstinence is crucial in stopping or reversing the progression of the disease. While maintaining good nutrition, taking lactulose (Cephulac), and using vitamin B supplements are important interventions in managing cirrhosis, abstaining from alcohol is the priority for this patient to prevent further damage to the liver and halt disease progression.
While receiving normal saline infusions to treat a GI bleed, the nurse notes that the patient's lower legs have become edematous and auscultates crackles in the lungs. What should the nurse do first?
- A. Stop the saline infusion immediately
- B. Notify the physician
- C. Elevate the patient's legs
- D. Continue the infusion, as these findings are normal
Correct Answer: A
Rationale: The correct answer is to stop the saline infusion immediately. The patient is showing signs of fluid volume overload due to rapid fluid replacement, indicated by lower leg edema and lung crackles. Continuing the infusion could worsen the overload and potentially lead to complications. Notifying the physician is important but should come after stopping the infusion to address the immediate issue. Elevating the patient's legs may help with edema but is not the priority in this situation. Continuing the infusion when the patient is already showing signs of fluid overload is contraindicated and can be harmful.
While taking the health history of a 70-year-old patient being treated for a Duodenal Ulcer, the nurse learns that the patient is complaining of epigastric pain. What assessment finding would the nurse expect to note?
- A. Melena
- B. Nausea
- C. Hernia
- D. Hyperthermia
Correct Answer: A
Rationale: Melena is the passage of black, tarry stools due to the presence of blood in the gastrointestinal tract, usually originating from the upper digestive system. In the context of a Duodenal Ulcer, melena can occur as a result of bleeding in the duodenum or the upper part of the small intestine. This finding is significant as it indicates potential gastrointestinal bleeding, which is a common complication of duodenal ulcers. Nausea (Choice B) is a nonspecific symptom that may be present with various gastrointestinal conditions but is not specific to duodenal ulcers. Hernia (Choice C) involves the protrusion of an organ through the wall of the cavity that normally contains it and is not directly related to the symptoms of a duodenal ulcer. Hyperthermia (Choice D), which refers to an elevated body temperature, is not typically associated with duodenal ulcers unless there are severe complications present.
When taking the blood pressure (BP) on the right arm of a patient with severe acute pancreatitis, the nurse notices carpal spasms of the patient's right hand. Which action should the nurse take next?
- A. Ask the patient about any arm pain.
- B. Retake the patient's blood pressure.
- C. Check the calcium level in the chart.
- D. Notify the healthcare provider immediately.
Correct Answer: C
Rationale: In this scenario, the nurse observed carpal spasms in the patient's right hand, indicating a positive Trousseau's sign, which is associated with hypocalcemia. Patients with acute pancreatitis are at risk for hypocalcemia, hence the nurse should promptly check the calcium level in the chart to assess the patient's condition. Notifying the healthcare provider comes after confirming the calcium level. There is no indication to ask about arm pain or to retake the blood pressure, as the primary concern is addressing the potential hypocalcemia.
Which of the following interventions should the nurse use when working with a Jackson-Pratt drain?
- A. Strip the tubing to remove clots by milking the tubing back toward the client
- B. Empty the drain when the amount of fluid reaches 25 cc
- C. Strip the tubing to remove clots by milking the tubing away from the client
- D. Maintain the level of the drain above the client's incision
Correct Answer: C
Rationale: A Jackson-Pratt drain is a type of active wound drain that may be placed following a surgical procedure. This drain actively draws excess blood and fluid out of the wound. If clots develop within the tubing, the nurse should strip the tubing by milking it in a direction away from the client. This action helps to ensure the drain remains patent and effective. Option A is incorrect because the tubing should be milked away from the client, not towards. Option B is incorrect as the drain should be emptied based on the healthcare provider's orders, not at a fixed volume. Option D is incorrect because the level of the drain should be below the level of the incision to allow drainage by gravity.