Chapter 13

The nurse is instructing a patient with acute pancreatitis on recommended dietary changes. Which statement by the patient indicates teaching has been effective?

1. "I am going to have to increase the protein in my diet to at least 75% of my intake." 2. "The largest component in my diet will be carbohydrates." 3. "It is important that fiber account for 40% of my diet during this acute period." 4. "I am going to need to cut fats totally out of my diet to protect my pancreas during my recovery." Correct Answer: 2

During pre-operative care, a patient asks the nurse "Why are they removing my gallbladder? I thought I had pancreatitis." What is the best response for the nurse to make?

1. "Only the surgeon can answer that question." 2. "You don't need to worry about the surgery. The surgeons know what they are doing." 3. "One common cause of acute pancreatitis is stones in your gallbladder." 4. "You said that you had gallbladder problems when you were admitted. The two are not connected." Correct Answer: 3

The nurse is assembling the equipment needed to begin caring for a patient with a gastrointestinal bleed who is hemodynamically unstable. What size of intravenous catheter would the nurse choose?

1. 22-gauge 2-inch angiocatheter 2. 18-gauge 1-inch angiocatheter 3. 22-gauge butterfly 4. 20-gauge 2-inch angiocatheter Correct Answer: 2

The nurse, completing the assessment of a patient with acute pancreatitis, would expect that the patient has a history of:

1. Alcohol abuse 2. CHF 3. Diabetes 4. Asthma Correct Answer: 1

The nurse is reviewing the laboratory values for a patient newly diagnosed with acute pancreatitis. Which values would the nurse expect to be elevated?

1. Amylase and lipase 2. Hemoglobin 3. Platelets 4. Prothrombin time Correct Answer: 1

A patient with severe acute pancreatitis has the following vital signs after fluid resuscitation: BP 84/53 mm Hg and HR 61 bpm. What would the nurse consider as next steps of care for this patient?

1. Assess for hypovolemic shock. 2. Prepare to administer diuretics. 3. Question if an antihypertensive would be indicated. 4. Prepare to administer potassium chloride. Correct Answer: 1

A patient being treated for a lower gastrointestinal bleed has a capillary refill of 3 seconds, a urinary output of 20 mL/hour, a heart rate of 88, and reports "feeling tired." Which finding should the nurse report to the physician?

1. Capillary refill of 3 seconds 2. Urinary output of 20 mL/hour 3. Heart rate of 88 bpm 4. Reports of fatigue Correct Answer: 2

A patient, being treated for acute gastrointestinal bleeding, is receiving 0.9% normal saline at 200 mL/hour through two large-bore IVs. What assessment finding would the nurse report immediately to the physician?

1. Crackles in both lung bases 2. Urinary output of 50 mL in 1 hour 3. Capillary refill of less than 2 seconds 4. Approximately 200 mL of coffee ground emesis Correct Answer: 1

A patient with a serious gastrointestinal bleed arrives in the emergency department and the physician intends to initiate aggressive intravenous therapy. Which solution would the nurse anticipate being used to manage this patient's condition?

1. D5 and NS 2. D5W 3. 0.9% NS 4. 0.45% NS Correct Answer: 3

A patient with symptoms consistent with pancreatitis reports feeling ill for the past week. Which diagnostic test will provide the most definitive diagnosis of pancreatitis?

1. Erythrocyte sedimentation rate 2. Serum lipase 3. Serum amylase 4. Complete blood count Correct Answer: 2

A patient arrives in the emergency department with clinical manifestations consistent with a lower gastrointestinal bleed. What should the nurse assess to determine the patient's stability?

1. Hemoglobin 2. Hematocrit 3. Vital signs 4. Abdominal rigidity to determine the amount of blood being lost Correct Answer: 3

A patient with severe acute pancreatitis has received aggressive fluid replacement therapy. Which assessment finding indicates management of this disorder has been effective?

1. Oxygen desaturation 2. Elevated heart rate 3. Decreasing hematocrit 4. Reduced blood pressure Correct Answer: 3

A patient with an active lower gastrointestinal bleed has the following vital signs: temperature 97.0 F, HR 68, RR 20, and BP 82/60 mm Hg. The nurse would place the patient in which position?

1. Prone 2. Supine with the legs bent at the knees 3. Supine with the legs raised 4. Side lying with the head of the bed elevated to 30 degrees Correct Answer: 3

A patient with an active gastrointestinal bleed has the following vital signs: BP 80/50 mm Hg, HR 102 bpm, RR 24, and oxygen saturation of 80%. The physician is writing orders for a blood transfusion to be provided at this time. What component of blood will the nurse anticipate the physician to order?

1. Whole blood 2. Packed red blood cells 3. Platelets 4. Fresh frozen plasma Correct Answer: 2

A patient with an upper gastrointestinal bleed asks why an endoscopy needs to be done. What would the nurse respond to this patient?

Select all that apply. 1. "It will identify where the bleeding is coming from." 2. "So the doctor can possibly stop the bleeding by injecting a medication into the area." 3. "The doctor may be able to stop the bleeding by sewing up the area that is bleeding." 4. "To figure out how much blood you will need to receive." 5. "To identify which antibiotics to prescribe for your treatment." Correct Answer: 1,2,3

A nurse is preparing a presentation for new graduates about pancreatitis. After attending the seminar, which statement by a graduate nurse indicates the need for additional instruction?

elect all that apply. 1. "Pancreatitis is typically idiopathic." 2. "There is only one single test finding that will diagnose pancreatitis." 3. "An indication of pancreatitis is an elevation in serum amylase during the first 3 to 5 days." 4. "Necrotizing pancreatitis is a commonly occurring complication." 5. The risk of hypovolemic shock is very high with this disorder. Correct Answer: 1,4

The nurse is teaching a patient about pancreatitis. What would the nurse include when instructing on the mechanism of the disease process?

Select all that apply. 1. "The exact mechanism is uncertain." 2. "Cells in the pancreas become damaged and release enzymes that injure the pancreas." 3. "Gall bladder stones block the ducts in the pancreas causing damage." 4. "A poor diet because of alcohol intake causes the pancreas to become inflamed." 5. "The pancreas contracts an infection from poor blood supply through the organ." Correct Answer: 1,2

A patient has been diagnosed with pancreatitis. What risk factors will help determine the severity of the patient's disease?

Select all that apply. 1. Age 2. Body weight 3. Chest x-ray findings 4. Oxygen saturation 5. Hemoglobin level Correct Answer: 1,2,3

During an assessment the nurse notifies the physician because a newly admitted patient is experiencing an upper gastrointestinal bleed. What findings would lead the nurse to this conclusion?

Select all that apply. 1. Black tarry stool 2. Bright red bloody emesis 3. Bright red rectal bleeding 4. Emesis with coffee grounds 5. Bloody sputum Correct Answer: 1,2,4

The nurse is assessing the effectiveness of pain management with morphine sulfate through a PCA pump in a patient with acute pancreatitis. Besides the patient's verbal response to the pain scale, what objective assessment findings indicate that the patient's pain level is decreasing?

Select all that apply. 1. Blood pressure increase 2. Slow, easy respirations 3. Pulse decrease 4. Facial grimacing 5. Blood pressure decrease Correct Answer: 2,3,5

The nurse is caring for a patient with severe pancreatitis. Which intravenous fluid would the nurse anticipate providing to this patient?

1. D5W 2. Lactated Ringer's 3. D51/2NS 4. 0.9% NS Correct Answer: 4

A patient recovering from a colonoscopy reports abdominal pain of 4 on a 5 point scale. The patient's abdomen is rigid and vital signs are T 99.2, HR 94, R 28, and BP 98/69. What initial action by the nurse is indicated?

1. Assist the patient to turn to aid in relieving the flatus buildup. 2. Continue to observe the patient for additional changes in 15 minutes. 3. Notify the physician. 4. Medicate the patient for discomfort. Correct Answer: 3

A patient with acute pancreatitis asks for something to eat. Which response by the nurse is most appropriate?

1. "Your physician will likely allow you to eat when the vomiting has subsided." 2. "You will be able to have a liquid diet within a week." 3. "Once your pain is in control and if your bowels are functioning normally, you will likely be able to begin a soft diet." 4. "During this time, you will have to get your nutrition from tube feedings." Correct Answer: 3

The nurse has been assigned to provide care for several patients on the medical-surgical unit. After reviewing the data exchanged during the shift report, which patient should the nurse plan to assess first? The patient with:

1. An elevated temperature of 99.2°F and complaints of nausea 2. Complaints of feelings of fullness and no bowel movement for 2 days 3. A heart rate of 82 bpm, complaints of fatigue, and an episode of coffee ground emesis 4 hours ago 4. Two episodes of melena diarrhea within the past 2 hours Correct Answer: 4

A patient, admitted to the ICU with a diagnosis of acute pancreatitis, is prescribed pain medication through a PCA pump. What will the nurse include when teaching the patient and family about the proper use of the pump?

1. The patient should only use the PCA pump when the pain is severe. 2. The family may help by "pushing the button" when they feel the patient is in pain. 3. The PCA allows the patient to administer smaller amounts of pain medication more frequently, which helps to get more effective pain relief. 4. The PCA delivers pain medication every time the button is pushed. Correct Answer: 3

A patient is surprised to learn the diagnosis of pancreatitis. Which risk factors should the nurse be certain to ask about during the assessment?

Select all that apply. 1. Frequency of alcohol intake 2. History of gall stones 3. List of current medications 4. History of smoking 5. History of peptic ulcer disease Correct Answer: 1,2,3,4

The nurse is completing the assessment of a patient admitted with an upper gastrointestinal bleed. Which risk factors should the nurse be certain to ask about during the assessment?

Select all that apply. 1. History of H. pylori 2. Routine use of NSAIDs 3. Use of aspirin 4. History of smoking 5. Diagnosis of diabetes Correct Answer: 1,2,3,4

The nurse assesses a patient and immediately notifies the physician because of findings consistent with a gastrointestinal bleed. What did the nurse assess in the patient?

Select all that apply. 1. Melena 2. Hematemesis 3. Confusion 4. Blood pressure of 180 /100 mm Hg 5. Absent bowel sounds Correct Answer: 1,2

A patient, being treated for a gastrointestinal bleed, has the following assessment findings: temperature 97.2°F, blood pressure 99/70 mm Hg, heart rate 74 bpm, capillary refill of 3 seconds, and oxygen saturation 94%. Four hours later the nurse identifies changes in the patient's condition. Which changes are associated with complications from management of the condition?

Select all that apply. 1. Temperature 98.2°F 2. Heart rate 98 bpm 3. Oxygen saturation 85% 4. Capillary refill of 2 seconds 5. Rales auscultated bilateral bases Correct Answer: 2,3,5

A patient being admitted to determine the presence of an upper gastrointestinal bleed does not believe the diagnosis because of the absence of pain. How would the nurse respond to this patient?

1. "Some patients have a high pain tolerance and are able to handle the condition better than others." 2. "Pain is not a typical symptom of this condition." 3. "You should share this with your physician next time you see him." 4. "You must be in the early stages of the disease because pain does not occur until later." Correct Answer: 2

A patient prescribed pantoprazole (Protonix) asks the purpose of the medication. Which response by the nurse is most appropriate?

1. "The medication will stop the stomach bleeding." 2. "The medication will provide a protective coating to your gastrointestinal system." 3. "The medication is used to reduce the acid in your gastric secretions and stabilize the clot to prevent further bleeding." 4. "The medication will eliminate any potential gastrointestinal infection you may have." Correct Answer: 3

A patient with acute pancreatitis is concerned about becoming addicted to the morphine prescribed for pain management. What response by the nurse is appropriate?

1. "You must only take the medication when the pain is intolerable." 2. "You may want to consider Demerol to manage your pain because it is less strong." 3. "Addiction during this period of acute pain is not likely." 4. "Addiction is a very real concern and should be considered when requesting medication." Correct Answer: 3

A patient being prepared for an endoscopy to diagnose an upper gastrointestinal bleed asks why a nasogastric tube has to be inserted. What would the nurse respond to this patient?

1. "You need this to assist with placement of the ostomy tube." 2. "The nasogastric tube will assist in the removal of blood clots that may limit the physician in seeing your esophagus." 3. "Your physician has left orders for placement of the tube." 4. "The tube will reduce the likelihood of you vomiting during the procedure." Correct Answer: 2

The nurse is concerned that a patient being treated for an acute upper gastrointestinal bleed is experiencing poor tissue perfusion because of which findings?

Select all that apply. 1. Flat jugular veins 2. Cold clammy skin 3. Capillary refill of 5 seconds 4. Narrowed pulse pressure 5. Bounding peripheral pulses Correct Answer: 1,2,3,4