Chapter 13

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

ANS: 1 Alcohol abuse is one risk factor for the development of acute pancreatitis.

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

ANS: 1 Amylase and lipase are enzymes excreted by the pancreas. In acute pancreatitis these levels will be increased to at least three times the normal level.

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

ANS: 1 Crackles on auscultation of the lungs suggest fluid overload and should be immediately reported to the physician.

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.

ANS: 1 If the patient's fluid status does not improve or worsens, consider hypovolemic shock.

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

ANS: 1, 2 Rationale 1: Melena is a common manifestation of gastrointestinal bleeding. Rationale 2: Hematemesis is a common manifestation of gastrointestinal bleeding.

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

ANS: 1, 2 Rationale 1: The exact mechanism as to how the different predisposing factors cause pancreatitis is uncertain. Rationale 2: It is believed that autodigestion occurs in the pancreas from the activation of trypsin.

A patient has been diagnosed with pancreatitis. What risk factors will help determine the severity of the patient's disease? Standard Text: Select all that apply. 1. Age 2. Body weight 3. Chest x-ray findings 4. Oxygen saturation 5. Hemoglobin level

ANS: 1, 2, 3 Rationale 1: An age greater than 55 is a risk factor for the severity of pancreatitis. Rationale 2: Obesity is a risk factor for the severity of pancreatitis. Rationale 3: Pulmonary infiltrates or pleural effusions are risk factors for the severity of pancreatitis.

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

ANS: 1, 2, 3 Rationale 1: The purpose of an endoscopy in patients with an acute GI bleed is to establish the site and etiology of the bleed. Rationale 2: During an endoscopy for upper gastrointestinal bleeding, injection therapy can be done to stop the bleeding. Through direct visualization, the site may be injected with a variety of agents to sclerose, vasoconstrict, or cause a tamponade effect. Rationale 3: Mechanical techniques to control gastrointestinal bleeding include the use of endoclips. These clips achieve hemostasis by compressing the tissue together. Its action is similar to that of a surgical stitch. Depending on the situation, multiple clips may be applied.

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

ANS: 1, 2, 3, 4 Rationale 1: Excessive alcohol use is a common risk factor for acute pancreatitis. Rationale 2: Gallstone disease is a common risk factor for acute pancreatitis. Rationale 3: Medications can cause acute pancreatitis although it is less common. Rationale 4: Smoking is an independent risk factor in the development of acute pancreatitis.

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

ANS: 1, 2, 3, 4 Rationale 1: Flat jugular veins indicate poor tissue perfusion in the patient with an acute gastrointestinal bleed. Rationale 2: Cold clammy skin indicates poor tissue perfusion in the patient with an acute gastrointestinal bleed. Rationale 3: A capillary refill of greater than 3 seconds indicates poor tissue perfusion in the patient with an acute gastrointestinal bleed. Rationale 4: Narrowed pulse pressure indicates poor tissue perfusion in the patient with an acute gastrointestinal bleed.

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? Standard Text: 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

ANS: 1, 2, 3, 4 Rationale 1: Helicobacter pylori cause the mucosa to be more susceptible to peptic acid damage and possible upper gastrointestinal bleeding. Rationale 2: Nonsteroidal anti-inflammatory drugs (NSAIDs) cause local and systemic effects that promote mucosal damage and potential gastrointestinal bleeding. Rationale 3: Aspirin causes local and systemic effects that promote mucosal damage and potential gastrointestinal bleeding. Rationale 4: Smoking is thought to increase the risk of developing ulcers and impair their healing.

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? Standard Text: 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

ANS: 1, 2, 4 Rationale 1: Melena is a manifestation of upper gastrointestinal bleeding. Rationale 2: Hematemesis is a manifestation of upper gastrointestinal bleeding. Rationale 4: Coffee ground emesis is seen in an upper gastrointestinal bleed that has slowed or stopped.

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? Standard Text: Select 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.

ANS: 1, 4 Rationale 1: There are a large number of predisposing factors associated with the development of pancreatitis. Additional teaching would be required. Rationale 4: Necrotizing pancreatitis is not a complication of the disorder as it is seen in only about 20% of the individuals. Additional teaching would be required.

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

ANS: 2 A large-bore IV catheter is needed to rapidly administer large volumes of intravenous fluids that hemodynamically unstable patients need.

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."

ANS: 2 After the resumption of dietary intake, carbohydrates will account for greater than 50% of intake along with a moderate intake of protein and fat.

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

ANS: 2 Patients who are hemodynamically unstable and have had considerable blood loss will require blood transfusions of packed red blood cells. Packed RBCs are preferred as this replaces the lost red blood cells, which will help improve oxygenation. The plasma will help expand volume.

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."

ANS: 2 The majority of upper gastrointestinal bleeding is painless.

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."

ANS: 2 The nasogastric tube may be utilized to reduce blood and aid removal of clots that might hinder observation by the physician during the test.

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

ANS: 2 The patient indicates that the illness has lasted for a week. The serum lipase results are more sensitive and will be most beneficial given the delay in seeking treatment. The serum lipase results will remain elevated for up to 14 days.

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

ANS: 2 The patient's urinary output is indicative of a worsening condition related to hypovolemia and reduced renal perfusion. Urinary output less than 30 cc/hour should be reported to the physician.

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

ANS: 2, 3, 5 Rationale 2: Respiratory rate will decrease to normal levels when pain is controlled. Rationale 3: The pulse decreases due to the decrease in pain and anxiety. Rationale 5: Pain control can be evidenced by a decrease in blood pressure due to decreased pain.

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? Standard Text: 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

ANS: 2, 3, 5 Rationale 2: Tachycardia is a manifestation of fluid overload. Rationale 3: Oxygen desaturation is a manifestation of fluid overload. Rationale 5: Abnormal lung sounds is a manifestation of fluid overload.

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

ANS: 3 Aggressive intravenous management of a patient with gastrointestinal bleeding is done with an isotonic crystalloid solution such as 0.9% NS. This type of fluid will provide intravascular fluid replacement to the depleted circulating fluid. This is done until the patient can be typed and crossed-matched for blood replacement therapy.

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."

ANS: 3 Dietary intake is typically resumed once the abdominal pain is in control, use of opiates is no longer needed, there is no anorexia, and bowel sounds have returned. New data suggests that initiating feeding with a low-fat soft diet is safe and can reduce hospitalizations as compared to a clear liquid diet

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

ANS: 3 Initially the hematocrit may be elevated as a result of fluid volume deficits. A reduction of the hematocrit toward the normal value is a sign that the fluid therapy has been successful.

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."

ANS: 3 One common cause of acute pancreatitis is gallstone disease. This is the best response for the nurse to make.

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.

ANS: 3 PCA is the preferred method of pain management. It allows the patient more control and provides more effective pain relief.

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."

ANS: 3 Pantoprazole (Protonix) is a proton pump inhibitor. Aggressive PPI treatment is used to maintain the gastric pH between 6.0 and 6.5 and is recommended to promote clot stability.

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

ANS: 3 The evaluation of vital signs is the best means to determine the patient's stability. Vital signs provide information concerning cardiac and vascular compensation.

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

ANS: 3 The patient's vital signs indicate distress. Placing the patient in a supine position with the legs elevated will promote the venous blood return to the heart. This will help the heart to fill and increase cardiac output and blood pressure.

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.

ANS: 3 The presence of abdominal rigidity following a colonoscopy may indicate the presence of a bowel perforation. The observations require prompt reporting to the physician.

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."

ANS: 3 The use of narcotic analgesics during periods of acute pain is unlikely to result in addiction. Prompt pain management is a key to care of this disorder.

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

ANS: 4 The patient with melena likely has an active gastrointestinal bleed. This is a serious health concern warranting further assessment and frequent evaluation by the nurse.

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

ANS: 4 The preferred intravenous solution for replacement during an episode of pancreatitis is 0.9% NS. The life-threatening manifestation of pancreatitis is hypovolemic shock because the patient becomes intravascularly depleted and needs isotonic fluid replacement.