1. Absent bowel sounds in all four (4) quadrants.
2. The T-tube with 60 mL of green drainage.
3. Urine output of 100 mL in the past three (3) hours.
4. Refusal to turn, deep breathe, and cough.
2. This is a normal amount and color of drainage.
3. The minimum urine output is 30 mL/hr.
**4. Refusing to turn, deep breathe, and cough puts the client at risk for pneumonia. This client needs immediate intervention to pre- vent complications.
TEST-TAKING HINT: The test taker should recognize normal data such as the normal urine output and normal data for postopera- tive clients. The test taker should apply basic concepts when answering questions. Normal or expected outcomes do not require action.
1. Apply a heating pad to the abdomen for 15 to 20 minutes.
2. Administer morphine sulfate intravenously after diluting with saline.
3. Contact the surgeon for an order to x-ray the right shoulder.
4. Apply a sling to the right arm that was injured in surgery.
2. Morphine sulfate would not affect the etiology of the pain.
3. The surgeon would not order an x-ray for this condition.
4. There is no indication that an injury occurred during surgery. A sling would not benefit the migration of the CO2.
TEST-TAKING HINT: The test taker must under- stand laparoscopic surgery to be able to answer this question. Option “4” could be eliminated because of the “injured during surgery” phrase that is making an assumption.
1. “I will take my lipid-lowering medicine at the same time each night.”
2. “I may experience some discomfort when I eat a high-fat meal.”
3. “I need someone to stay with me for about a week after surgery.”
4. “I should not splint my incision when I deep breathe and cough.”
**2. After removal of the gallbladder, some clients experience abdominal discomfort when eating fatty foods.
3. Laparoscopic cholecystectomy surgeries are performed in day surgery, and clients usually do not need assistance for a week.
4. Using a pillow to splint the abdomen provides support for the incision and should be continued after discharge.
TEST-TAKING HINT: When answering questions that state “teaching is effective,” the test taker should look for the correct information. Basic concepts should help the test taker answer questions and, because pain often occurs after surgeries, answer option “2” would probably be a correct answer if the test taker had no idea which option is correct.
1. Clay-colored stools.
2. Yellow-tinted sclera.
3. Dark yellow urine.
4. Feverish chills.
5. Abdominal pain.
2. Yellow-tinted sclera and skin indicate residual effects of stricture of the common bile duct, which is a sign of post-cholecystectomy syndrome.
3. Dark yellow urine indicates a residual effect of a stricture of the common bile duct, which is a sign of post-cholecystectomy syndrome.
4. Fever and chills indicate residual or recur- ring calculi, inflammation, or stricture of common bile duct, which is a sign of post- cholecystectomy syndrome.
5. Abdominal pain indicates a residual effect of a stricture of common bile duct, inflammation, or calculi, which is a sign of post- cholecystectomy syndrome.
TEST-TAKING HINT: The test taker must use knowledge of anatomy to answer this question. All answer options have something to do with the abdominal area, and the common bile duct is anatomically near the hepatic duct, which causes the liver signs/symptoms.
1. Check the abdominal dressings for bleeding.
2. Increase the IV fluid if the blood pressure is low.
3. Document the amount of output on the I & O sheet.
4. Listen to the breath sounds in all lobes.
2. This intervention would require analysis.
**3. This intervention would be appropriate for the nursing assistant to implement.
4. This would require assessment and cannot be delegated.
TEST-TAKING HINT: The nurse cannot delegate teaching, assessing, and evaluating to a nursing assistant. The nurse cannot delegate any nursing task unless the client is stable and the task does not require judgment.
1. Chalky white stools.
2. Increased heart rate.
3. A firm hard abdomen.
4. Hyperactive bowel sounds.
2. This would be abnormal data and would be cause for further assessment.
3. This would not be expected from the test.
4. This is a serious finding and should be treated.
TEST-TAKING HINTS: Answer option “2” could be eliminated because it does not have any- thing to do with the gastrointestinal system. A firm hard abdomen is very seldom ever expected, so “3” could be eliminated.
1. Instruct the client to cough forcefully.
2. Encourage early ambulation.
3. Assess for return of a gag reflex.
4. Administer held medications.
2. This would not enhance safety.
3. The endoscopic retrograde cholangiopan- creatogram (ERCP) requires that an anesthetic spray be used prior to insertion of the endoscope. If medications, food, or fluid is given orally prior to the return of the gag reflex, the client may aspirate, causing pneumonia that could be fatal.
4. Medications would not be given until the gag reflex has returned.
TEST-TAKING HINTS: The test taker must notice adjectives such as “endoscopic,” which means the procedure includes going down the mouth; “3” is the only option that has anyth- ing to do with the mouth. If the test taker had no idea of the correct answer, selecting a distracter addressing assessment would be appropriate because assessment is the first step of the nursing process.
1. Decreased pain management.
2. Ambulate first day postoperative.
3. No break in skin integrity.
4. Knowledge of postoperative care.
2. Postoperative care would include ambulation.
3. Prevention of an additional break in skin integrity would be a desired postoperative out- come. The incision would be a break in skin integrity.
**4. This would be an expected outcome for the client scheduled for surgery. This indicates that preoperative teaching has been effective.
TEST-TAKING HINT: The time element is impor- tant in this question. The “expected outcome” that is required is for before the client’s surgery. Option “1” is wrong because of the adjective “decreased.” Adjectives commonly determine the accuracy of answer options.
1. The client’s pulse is 65 beats per minute.
2. The client has shallow respirations.
3. The client’s bowel sounds are 20 per minute.
4. The client uses a pillow to splint when coughing
**2. Clients having abdominal pain frequently have shallow respirations. When assessing clients for pain, the nurse should discuss pain medication with any client who has shallow respirations.
3. These are normal data and would not require further action.
4. Splinting the abdomen allows the client to increase the strength of the cough by increasing comfort and would not indicate a need for pain medication.
TEST-TAKING HINT: The stem asks which data would warrant pain medication. Therefore the test taker should select an answer that is not expected or is not normal for clients who are postoperative abdominal surgery.
1. An elevated white blood cell (WBC) count.
2. A decreased lactate dehydrogenase (LDH)
3. An elevated alkaline phosphatase. 4. A decreased direct bilirubin level.
2. This value would indicate liver abnormalities.
3. This value would indicate liver abnormalities.
4. This value would indicate an obstructive
TEST-TAKING HINT: If the test taker does not know what the values mean, the test taker should look to the disease process. The “itis” means inflammation, and an educated guess would be that WBCs are elevated in inflamma- tory processes.
1. Alteration in nutrition.
2. Alteration in skin integrity.
3. Alteration in urinary pattern.
4. Alteration in comfort.
2. This may be an appropriate client problem, but is not priority.
3. This may be an appropriate client problem, but is not priority.
4. Acute pain management is the highest priority client problem after surgery because pain may indicate a life-threatening problem.
TEST-TAKING HINT: When a question asks for the highest priority, the test taker should look for life-threatening problems that would be the highest priority for intervention. Pain may be expected, but it may indicate a complication.
1. Measure the abdominal girth.
2. Palpate the lower abdomen for a mass.
3. Turn client onto side to assess for further drainage.
4. Remove the dressing to determine the source.
2. This would assess the bladder, not bleeding.
**3. Turning the client to the side to assess the amount of drainage and possible bleeding is important prior to contacting the surgeon.
4. The first dressing change is usually done by the surgeon; the nurse would reinforce the dressing.
TEST-TAKING HINT: The adjectives “large” and “red” indicate that the client is bleeding, and assessment is always priority when the client is having a possible complication of a surgery. Remember assessment is the first step in the nursing process.