Test 2 part 1
A nurse is caring for a patient with constipation whose primary care provider has recommended senna Senokot for the management of this condition. The nurse should provide which of the following education points?
"Avoid taking the drug on a long-term basis."
patient's assessment and diagnostic testing are suggestive of acute pancreatitis. nurse is performing the health interview, assessment questions address likely etiologic factors? Have you ever been diagnosed with gallstones?"
"How many alcoholic drinks do you typically consume in a week?"Eighty percent of patients with acute pancreatitis have biliary tract disease such as gallstones or a history of long-term alcohol abuse.
The management of the patient's gastrostomy is an assessment priority for the home care nurse. What statement would indicate that the patient is managing the tube correctly?
"I flush my tube with water before and after each of my medications."
The family of a patient in the ICU diagnosed with acute pancreatitis asks the nurse why the patient has been moved to an air bed. What would be the nurse's best response?
"The bed automatically moves, so she's less likely to develop pressure sores while she's in bed."
A triage nurse in the emergency department is assessing a patient who presented with complaints of general malaise. Assessment reveals the presence of jaundice and increased abdominal girth.
"What assessment question best addresses the possible etiology of this patient's presentation? How many alcoholic drinks do you typically consume in a week?"
A patient with end-stage liver disease has developed hypervolemia. What nursing interventions would be most appropriate when addressing the patient's fluid volume excess? Select all that apply.
Administering diuretics, implementing fluid restrictions, and enhancing patient positioning can optimize the management of fluid volume excess.
A nurse is amending a patient's plan of care in light of the fact that the patient has recently developed ascites. What should the nurse include in this patient's care plan?
Administration of diuretics as ordered Use of diuretics along with sodium restriction is successful in 90% of patients with ascites.
patient's physician has ordered a "liver panel" in response to the patient's development of jaundice. When reviewing the results of this laboratory testing, the nurse should expect to review what blood tests?
Alanine aminotransferase (ALT) Gamma-glutamyl transferase (GGT) Aspartate aminotransferase (AST)
A patient's health history is suggestive of inflammatory bowel disease. Which of the following would suggest Crohn's disease, rather that ulcerative colitis, as the cause of the patient's signs and symptoms?
An absence of blood in stool
A patient with dysphagia is scheduled for PEG tube insertion and asks the nurse how the tube will stay in place. What is the nurse's best response?
An internal retention disc secures the tube against the stomach wall.
A patient has been scheduled for an ultrasound of the gallbladder the following morning. What should the nurse do in preparation for this diagnostic study? Have the patient refrain from food and fluids after midnight.
An ultrasound of the gallbladder is most accurate if the patient fasts overnight, so that the gallbladder is distended.
A patient is concerned about leakage of gastric contents out of the gastric sump tube the nurse has just inserted. What would the nurse do to prevent reflux gastric contents from coming through the blue vent of a gastric sump tube?
Ans: Keep the vent lumen above the patient's waist.
A nurse is preparing to place a patient's ordered nasogastric tube. How should the nurse best determine the correct length of the nasogastric tube?
Ans: Place distal tip to nose, then ear tip and end of xiphoid process.
The nurse is providing care for a patient whose inflammatory bowel disease has necessitated hospital treatment. Which of the following would most likely be included in the patient's medication regimen?
Anticholinergic medications 30 minutes before a meal
A patient has had an ileostomy created for the treatment of irritable bowel disease and the patient is now preparing for discharge. What should the patient be taught about changing this device in the home setting?
Apply a skin barrier to the peristomal skin prior to applying the pouch.
An older adult who resides in an assisted living facility has sought care from the nurse because of recurrent episodes of constipation. Which of the following actions should the nurse first perform?
Assess the patient's food and fluid intake.
A patient with liver cancer is being discharged home with a biliary drainage system in place. The nurse should teach the patient's family how to safely perform which of the following actions?
Assessing the patency of the drainage catheter Families should be taught to provide basic catheter care, including assessment of patency
A nurse is caring for a patient who has been admitted for the treatment of advanced cirrhosis. What assessment should the nurse prioritize in this patient's plan of care?
Assessment for variceal bleeding Esophageal varices are a major cause of mortality in patients with uncompensated cirrhosis
A nurse is caring for a patient with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the patient has a flapping tremor of the hands. The nurse should document the presence of what sign of liver disease?
Asterixis The nurse will document that a patient exhibiting a flapping tremor of the hands is demonstrating asterixis.
A patient's NG tube has become clogged after the nurse instilled a medication that was insufficiently crushed. The nurse has attempted to aspirate with a large-bore syringe, with no success. What should the nurse do next?
Attach a syringe filled with warm water and attempt an in-and-out motion of instilling and aspirating.
A nurse has obtained an order to remove a patient's NG tube and has prepared the patient accordingly. After flushing the tube and removing the nasal tape, the nurse attempts removal but is met with resistance
Because the nurse is unable to overcome this resistance, what is the most appropriate action? Report this finding to the patient's primary care provider.
As a result, surgical risks have decreased, along with the length of hospital stay and the long recovery period required after standard surgical cholecystectomy.
Both approaches allow for removal of the entire gallbladder and must be performed under general anesthetic in an operating theater.
patient with cirrhosis has experienced a progressive decline in his health; and liver transplantation is being considered by the interdisciplinary team. How will the patient's prioritization for receiving a donor liver be determined?
By objectively determining the patient's medical need The patient would undergo a classification of the degree of medical need through an objective determination known as the Model of End-Stage Liver Disease
A nurse is teaching a group of adults about screening and prevention of colorectal cancer. The nurse should describe which of the following as the most common sign of possible colon cancer?
Change in bowel habits
A nurse is aware of the high incidence of catheter-related bloodstream infections in patients receiving parenteral nutrition. What nursing action has the greatest potential to reduce catheter-related bloodstream infections?
Change the dressing no more than weekly.
A patient has been discharged home on parenteral nutrition (PN). Much of the nurse's discharge education focused on coping. What must a patient on PN likely learn to cope with? Select all that apply.
Changes in lifestyle, Loss of eating as a social behavior, Sleep disturbances related to frequent urination during nighttime infusions
The nurse is administering total parenteral nutrition (TPN) to a client who underwent surgery for gastric cancer. Which of the nurse's assessments most directly addresses a major complication of TPN?
Checking the patient's capillary blood glucose levels regularly
A nurse is creating a care plan for a patient who is receiving parenteral nutrition. The patient's care plan should include nursing actions relevant to what potential complications? Select all that apply.
Clotted or displaced catheter, Pneumothorax, Hyperglycemia, Line sepsis .
A patient's new onset of dysphagia has required insertion of an NG tube for feeding; the nurse has modified the patient's care plan accordingly. What intervention should the nurse include in the patient's plan of care?
Confirm placement of the tube prior to each medication administration.
A patient is receiving care in the intensive care unit for acute pancreatitis. The nurse is aware that pancreatic necrosis is a major cause of morbidity and mortality in patients with acute pancreatitis.
Consequently, the nurse should assess for what signs or symptoms of this complication? Fever, increased heart rate and decreased blood pressure
A nurse is working with a patient who has chronic constipation. What should be included in patient teaching to promote normal bowel function?
Consume high-residue, high-fiber foods.
A nurse is providing care for a patient whose recent colostomy has contributed to a nursing diagnosis of Disturbed Body Image Related to Colostomy. What intervention best addresses this diagnosis?
Engage the patient in the care of the ostomy to the extent that the patient is willing.
A patient's enteral feedings have been determined to be too concentrated based on the patient's development of dumping syndrome. What physiologic phenomenon caused this patient's complication of enteral feeding?
Entry of large amounts of water into the small intestine because of osmotic pressure
nurse who provides care in a walk-in clinic assesses a wide range of individuals. nurse should identify which of the following patients as having the highest risk for chronic pancreatitis? A 39-year-old man with chronic alcoholism
Excessive and prolonged consumption of alcohol accounts for approximately 70% to 80% of all cases of chronic pancreatitis.
The nurse is caring for a patient who has just returned from the ERCP removal of gallstones. The nurse should monitor the patient for signs of what complications? Bleeding and perforation
Following ERCP removal of gallstones, the patient is observed closely for bleeding, perforation, and the development of pancreatitis or sepsis.
A patient with portal hypertension has been admitted to the medical floor. The nurse should prioritize which of the following assessments related to the manifestations of this health problem?
Daily weights and abdominal girth measurement
patient with a diagnosis of cirrhosis has developed variceal bleeding and will imminently undergo variceal banding. What psychosocial nursing diagnosis should the nurse prioritize during this phase of the patient's treatment?
Death Anxiety The sudden hemorrhage that accompanies variceal bleeding is intensely anxiety-provoking. The nurse must address the patient's likely fear of death, which is a realistic possibility
Prior to a patient's scheduled jejunostomy, the nurse is performing the preoperative assessment. What goal should the nurse prioritize during the preoperative assessment?
Determining the patient's ability to understand and cooperate with the procedure
A patient receiving tube feedings is experiencing diarrhea. The nurse and the physician suspect that the patient is experiencing dumping syndrome. What intervention is most appropriate?
Dilute the concentration of the feeding solution.
A nurse is assessing a patient's stoma on postoperative day 3. The nurse notes that the stoma has a shiny appearance and a bright red color. How should the nurse best respond to this assessment finding?
Document that the stoma appears healthy and well perfused.
An adult patient has been admitted to the medical unit for the treatment of acute pancreatitis. What nursing action should be included in this patient's plan of care? Measure the patient's abdominal girth daily.
Due to the risk of ascites, the nurse should monitor the patient's abdominal girth.
These complications often lead to the need for dietary modifications. Pancreatic enzyme replacement, a low-fat diet, and vitamin supplementation often are also required to meet the patient's nutritional needs and restrictions.
Electrolyte imbalances often accompany pancreatic disorders and surgery, but the electrolyte levels are more often deficient than excessive. Weight loss is a common complication,
A patient presents to the ED complaining of severe right upper quadrant pain. The patient states that his family doctor told him he had gallstones. The ED nurse should recognize what possible complication of gallstones?
Gangrene of the gallbladder In calculous cholecystitis, a gallbladder stone obstructs bile outflow. Bile remaining in the gallbladder initiates a chemical reaction;
autolysis and edema occur; and the blood vessels in the gallbladder are compressed, compromising its vascular supply.
Gangrene of the gallbladder with perforation may result. Pancreatitis, atrophy, and cancer of the gallbladder are not plausible complications.
The nurse is caring for a patient who is postoperative from having a gastrostomy tube placed. What should the nurse do on a daily basis to prevent skin breakdown?
Gently rotate the tube.
During a health education session, a participant has asked about the hepatitis E virus. What prevention measure should the nurse recommend for preventing infection with this virus?Following proper hand-washing techniques
Hepatitis E is transmitted by the fecal-oral route, principally through contaminated water in areas with poor sanitation.
A nurse is presenting an educational event to a local community group. When speaking about colorectal cancer, what risk factor should the nurse cite?
High levels of alcohol consumption
A nurse is participating in the emergency care of a patient who has just developed variceal bleeding. What intervention should the nurse anticipate?
IV administration of octreotide (Sandostatin)
A nurse is caring for a patient with a blocked bile duct from a tumor. What manifestation of obstructive jaundice should the nurse anticipate? Orange and foamy urine
If the bile duct is obstructed, the bile will be reabsorbed into the blood and carried throughout the entire body. It is excreted in the urine, which becomes deep orange and foamy.
A patient's abdominal ultrasound indicates cholelithiasis. When the nurse is reviewing the patient's laboratory studies, what finding is most closely associated with this diagnosis? Increased bilirubin
If the flow of blood is impeded, bilirubin, a pigment derived from the breakdown of red blood cells, does not enter the intestines. As a result, bilirubin levels in the blood increase.
A nurse educator is teaching a group of recent nursing graduates about their occupational risks for contracting hepatitis B. What preventative measures should the educator promote? Select all that apply.
Immunization Use of standard precautions
A nurse on a solid organ transplant unit is planning the care of a patient who will soon be admitted upon immediate recovery following liver transplantation. What aspect of nursing care is the nurse's priority?
Implementation of infection-control measures
The nurse is assessing placement of a nasogastric tube that the patient has had in place for 2 days. The tube is draining green aspirate. What is the nurse's most appropriate action?
Leave the tube in its present position.
Diagnostic testing has revealed that a patient's hepatocellular carcinoma (HCC) is limited to one lobe. The nurse should anticipate that this patient's plan of care will focus on what intervention?
Lobectomy
A patient has been diagnosed with a small bowel obstruction and has been admitted to the medical unit. The nurse's care should prioritize which of the following outcomes?
Maintaining fluid and electrolyte balance
A patient has a gastrostomy tube that has been placed to drain stomach contents by low intermittent suction. What is the nurse's priority during this aspect of the patient's care?
Measure and record drainage.
A patient with ongoing back pain, nausea, and abdominal bloating has been diagnosed with cholecystitis secondary to gallstones.nurse should anticipate that the patient will undergo what intervention?Laparoscopic cholecystectomy
Most of the nonsurgical approaches, including lithotripsy and dissolution of gallstones, provide only temporary solutions to gallstone problems and are infrequently used in the United States. Cholecystectomy is the preferred treatment.
A patient's physician has determined that for the next 3 to 4 weeks the patient will require parenteral nutrition (PN). The nurse should anticipate the placement of what type of venous access device?
Nontunneled central catheter
A patient has been brought to the emergency department by EMS after telling a family member that he deliberately took an overdose of NSAIDs a few minutes earlier. If lavage is ordered, the nurse should prepare to assist with the insertion of what type of tube?
Orogastric tube
A patient has been diagnosed with pancreatic cancer and has been admitted for care. Following initial treatment, the nurse should be aware that the patient is most likely to require which of the following? Hospice care
Pancreatic carcinoma has only a 5% survival rate at 5 years regardless of the stage of disease at diagnosis or treatment.
A nurse is providing care for a patient who has a diagnosis of irritable bowel syndrome (IBS). When planning this patient's care, the nurse should collaborate with the patient and prioritize what goal?
Patient will accurately identify foods that trigger symptoms.
A nurse is caring for a patient with cirrhosis secondary to heavy alcohol use. The nurse's most recent assessment reveals subtle changes in the patient's cognition and behavior. What is the nurse's most appropriate response?
Report this finding to the primary care provider due to the possibility of hepatic encephalopathy. The nurse monitors the patient's mental status closely and reports changes so that treatment of encephalopathy can be initiated
nurse is assessing a patient who has been diagnosed with cholecystitis, and is experiencing localized abdominal pain. assessing the characteristics of the patient's pain, the nurse anticipates that it may radiate to what region?
Right shoulder.The patient may have biliary colic with excruciating upper right abdominal pain that radiates to the back or right shoulder.
A nurse is writing a care plan for a patient with a nasogastric tube in place for gastric decompression. What risk nursing diagnosis is the most appropriate component of the care plan?
Risk for Impaired Skin Integrity Related to the Presence of NG Tube
A patient is being discharged after a liver transplant and the nurse is performing discharge education. When planning this patient's continuing care, the nurse should prioritize which of the following risk diagnoses?
Risk for Infection Related to Immunosuppressant Use
A nurse is caring for a patient with a subclavian central line who is receiving parenteral nutrition (PN). In preparing a care plan for this patient, what nursing diagnosis should the nurse prioritize?
Risk for Infection Related to the Presence of a Subclavian Catheter
A teenage patient with a pilonidal cyst has been brought for care by her mother. The nurse who is contributing to the patient's care knows that treatment will be chosen based on what risk?
Risk for infection
A nurse is assessing an elderly patient with gallstones. The nurse is aware that the patient may not exhibit typical symptoms, and that particular symptoms that may be exhibited in the elderly patient may include what?
Signs and symptoms of septic shock.elderly may not exhibit symptoms of fever, pain, chills jaundice, and nausea and vomiting. Symptoms of biliary tract disease in the elderly oliguria, hypotension, change in mental status, tachycardia, and tachypnea.
Pancreatic necrosis is a major cause of morbidity and mortality in patients with acute pancreatitis because of resulting hemorrhage, septic shock, and multiple organ dysfunction syndrome (MODS).
Signs of shock would include hypotension, tachycardia and fever. Each of the other listed changes in status warrants intervention, but none is clearly suggestive of an onset of pancreatic necrosis.
assessment reveals that the patient exhibits episodes of confusion, is difficult to arouse from sleep and has rigid extremities. Based on these clinical findings, the nurse should document what stage of hepatic encephalopathy?
Stage 3 are stuporous, difficult to arouse, sleeps most of the time, exhibits marked confusion, incoherent in speech, asterixis, increased deep tendon reflexes, rigidity of extremities, marked EEG abnormalities.
The nurse is preparing to insert a patient's ordered NG tube. What factor should the nurse recognize as a risk for incorrect placement?
The patient is agitated.
A nurse is caring for a patient with a nasogastric tube for feeding. During shift assessment, the nurse auscultates a new onset of bilateral lung crackles and notes a respiratory rate of 30 breaths per minute.
The patient's oxygen saturation is 89% by pulse oximetry. After ensuring the patient's immediate safety, what is the nurse's most appropriate action? Report possible signs of aspiration pneumonia to the primary care provider.
A patient's screening colonoscopy revealed the presence of numerous polyps in the large bowel. What principle should guide the subsequent treatment of this patient's health problem?
The patient's polyps constitute a risk factor for cancer.
Pain relief from a pancreaticojejunostomy often occurs by 6 months in more than 85% of the patients who undergo this procedure, but pain returns in a substantial number of patients as the disease progresses.
This patient had surgery 3 months ago; the patient has 3 months before optimal benefits of the procedure may be experienced
A nurse caring for a patient with colorectal cancer is preparing the patient for upcoming surgery. The nurse administers cephalexin (Keflex) to the patient and explains what rationale?
To reduce intestinal bacteria levels
A community health nurse is caring for a patient whose multiple health problems include chronic pancreatitis. During the most recent visit, the nurse notes that the patient is experiencing severe abdominal pain and has
vomited 3 times in the past several hours. What is the nurse's most appropriate action? The onset of these acute symptoms warrants hospital treatment.
patient has been admitted to the critical care unit with a diagnosis of toxic hepatitis. When planning the care, the nurse should be aware of what potential clinical course of this health problem? the events in the correct sequence.
1. Fever rises. 2. Hematemesis. 3. Clotting abnormalities. 4. Vascular collapse. 5. Coma.
You are caring for a patient who was admitted to have a low-profile gastrostomy device (LPGD) placed. How soon after the original gastrostomy tube placement can an LPGD be placed?
2 to 3 months
A patient has a recent diagnosis of chronic pancreatitis and is undergoing diagnostic testing to determine pancreatic islet cell function. The nurse should anticipate what diagnostic test? Glucose tolerance test
A glucose tolerance test evaluates pancreatic islet cell function and provides necessary information for making decisions about surgical resection of the pancreas.
A nursing instructor is discussing hemorrhoids with the nursing class. Which patients would the nursing instructor identify as most likely to develop hemorrhoids?
A pregnant woman at 28 weeks' gestation
A patient with a history of injection drug use has been diagnosed with hepatitis C. When collaborating with the care team to plan this patient's treatment, the nurse should anticipate what intervention?
A regimen of antiviral medications of two antiviral agents, Peg-interferon and ribavirin Rebetol, is effective in producing improvement in patients with hepatitis C and in treating relapses.
A nurse is performing an admission assessment for an 81-year-old patient who generally enjoys good health. When considering normal, age-related changes to hepatic function, the nurse should anticipate what finding?
A slightly decreased size of the liver
Severe abdominal pain is the major symptom of pancreatitis that causes the patient to seek medical care. Pain in pancreatitis is accompanied by nausea and vomiting that does not relieve the pain or nausea.
Abdominal guarding is present and a rigid or board-like abdomen may be a sign of peritonitis. Ecchymosis (bruising) to the flank or around the umbilicus may indicate severe peritonitis. Pain generally occurs 24 to 48 hours after a heavy meal or alcohol ingestion.
A patient has been diagnosed with advanced stage breast cancer and will soon begin aggressive treatment. What assessment findings would most strongly suggest that the patient may have developed liver metastases?
Abdominal pain and hepatomegaly
A nurse is caring for a patient who has been admitted to the hospital with diverticulitis. Which of the following would be appropriate nursing diagnoses for this patient? Select all that apply.
Acute Pain Related to Increased Peristalsis and GI Inflammation, Activity Intolerance Related to Generalized Weakness, Deficient Fluid Volume Related to Anorexia, Nausea, and Diarrhea
A nurse is caring for a patient admitted with symptoms of an anorectal infection; cultures indicate that the patient has a viral infection. The nurse should anticipate the administration of what drug?
Acyclovir Zovirax
A nurse is caring for a patient who has an order to discontinue the administration of parenteral nutrition. What should the nurse do to prevent the occurrence of rebound hypoglycemia in the patient?
Administer an isotonic dextrose solution for 1 to 2 hours after discontinuing the PN.
An adult patient has been diagnosed with diverticular disease after ongoing challenges with constipation. The patient will be treated on an outpatient basis. What components of treatment should the nurse anticipate?
Increased fiber intake, Reduced fat intake
A nurse is preparing to administer a patient's scheduled parenteral nutrition (PN). Upon inspecting the bag, the nurse notices that the presence of small amounts of white precipitate are present in the bag. What is the nurse's best action?
Contact the pharmacy to obtain a new bag of PN.
During a patient's scheduled home visit, an older adult patient has stated to the community health nurse that she has been experiencing hemorrhoids of increasing severity in recent months. The nurse should recommend which of the following?
Increased fluid and fiber intake
A nurse is caring for a patient who is receiving parenteral nutrition. When writing this patient's plan of care, which of the following nursing diagnoses should be included?
Ineffective Role Performance Related to Parenteral Nutrition
Which of the following is the most plausible nursing diagnosis for a patient whose treatment for colon cancer has necessitated a colonostomy?
Ineffective Sexuality Patterns Related to Changes in Self-Concept
A patient is admitted to the medical unit with a diagnosis of intestinal obstruction. When planning this patient's care, which of the following nursing diagnoses should the nurse prioritize?
Ineffective Tissue Perfusion Related to Bowel Ischemia
A nurse is initiating parenteral nutrition (PN) to a postoperative patient who has developed complications. The nurse should initiate therapy by performing which of the following actions?
Initiating the infusion slowly and monitoring the patient's fluid and glucose tolerance
A 35-year-old male patient presents at the emergency department with symptoms of a small bowel obstruction. In collaboration with the primary care provider, what intervention should the nurse prioritize?
Insertion of a nasogastric tube
A student nurse is caring for a patient who has a diagnosis of acute pancreatitis and who is receiving parenteral nutrition. The student should prioritize which of the following assessments? Blood glucose levels
In addition to administering enteral or parenteral nutrition, the nurse monitors serum glucose levels every 4 to 6 hours. Output should be monitored but in most cases it is not more important than serum glucose levels.
A patient with liver cancer is being discharged home with a hepatic artery catheter in place. The nurse should be aware that this catheter will facilitate which of the following? Delivery of a continuous chemotherapeutic dose
In most cases, the hepatic artery catheter has been inserted surgically and has a prefilled infusion pump that delivers a continuous chemotherapeutic dose until completed.
A critical care nurse is caring for a patient diagnosed with acute pancreatitis. The nurse knows that the indications for starting parenteral nutrition (PN) for this patient are what?
Inability to take in adequate oral food or fluids within 7 days
patient who had surgery for gallbladder disease has just returned to the postsurgical unit from postanesthetic recovery. nurse caring for this patient knows to immediately report what assessment finding
Increased abdominal tenderness and rigidity should be reported immediately to the physician, as it may indicate bleeding from an inadvertent puncture or nicking of a major blood vessel during the surgical procedure.
A nurse is preparing to administer a patient's intravenous fat emulsion simultaneously with parenteral nutrition (PN). Which of the following principles should guide the nurse's action?
Intravenous fat emulsions may be infused simultaneously with PN through a Y-connector close to the infusion site and should not be filtered.
A nurse is performing an admission assessment of a patient with a diagnosis of cirrhosis. What technique should the nurse use to palpate the patient's liver?
Place hand under right lower rib cage and press down lightly with the other hand.
A patient with a liver mass is undergoing a percutaneous liver biopsy. What action should the nurse perform when assisting with this procedure?
Position the patient on the right side with a pillow under the costal margin after the procedure.
A nurse is caring for an older adult who has been experiencing severe Clostridium difficile-related diarrhea. When reviewing the patient's most recent laboratory tests, the nurse should prioritize which of the following?
Potassium level
A nurse is admitting a patient to the postsurgical unit following a gastrostomy. When planning assessments, the nurse should be aware of what potential postoperative complication of a gastrostomy?
Premature removal of the G tube
A patient's large bowel obstruction has failed to resolve spontaneously and the patient's worsening condition has warranted admission to the medical unit. Which of the following aspects of nursing care is most appropriate for this patient?
Preparing the patient for surgical bowel resection
A nurse is preparing to discharge a patient home on parenteral nutrition. What should an effective home care teaching program address? Select all that apply.
Preparing the patient to troubleshoot for problems, Teaching the patient and family strict aseptic technique, Teaching the patient and family how to set up the infusion
A nursing educator is reviewing the care of patients with feeding tubes and endotracheal tubes (ET). The educator has emphasized the need to check for tube placement in the stomach as well as residual volume. What is the main purpose of this nursing action?
Prevent aspiration
A nurse is caring for a patient with severe hemolytic jaundice. Laboratory tests show free bilirubin to be 24 mg/dL. For what complication is this patient at risk? Central nervous system damage
Prolonged jaundice, even if mild, predisposes to the formation of pigment stones in the gallbladder, and extremely severe jaundice levels of free bilirubin exceeding 20 to 25 poses a risk for CNS damage.
A patient with liver disease has developed jaundice; the nurse is collaborating with the patient to develop a nutritional plan. The nurse should prioritize which of the following in the patient's plan?
Reduction in sodium intake
A nurse is participating in a patient's care conference and the team is deciding between parenteral nutrition (PN) and a total nutritional admixture (TNA). What advantages are associated with providing TNA rather than PN?
TNA is less costly than PN.
A nurse at an outpatient surgery center is caring for a patient who had a hemorrhoidectomy. What discharge education topics should the nurse address with this patient?
The correct procedure for taking a sitz bath
A nurse is assisting with serving dinner trays on the unit. Upon receiving the dinner tray for a patient admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray?Fried chicken
The diet immediately after an episode of acute cholecystitis is initially limited to low-fat liquids. Cooked fruits, rice or tapioca, lean meats, mashed potatoes, bread, and coffee or tea may be added as tolerated.
A nurse is preparing a plan of care for a patient with pancreatic cysts that have necessitated drainage through the abdominal wall. What nursing diagnosis should the nurse prioritize? Impaired Skin Integrity
The drainage is often perfuse and destructive to tissue because of the enzyme contents. Nurse must focus on steps to protect the skin near the drainage site from excoriation. application of ointments or the use of a suction apparatus
stones, dissolve small stones, and prevent new stones from forming. Six to 12 months of therapy is required in many patients to dissolve stones, and monitoring of the patient is required during this time.
The effective dose of medication depends on body weight.
A 55-year-old man has been newly diagnosed with acute pancreatitis and admitted to the acute medical unit. How should the nurse most likely explain the pathophysiology of this patient's health problem?
The enzymes that your pancreas produces have damaged the pancreas itself."Although the mechanisms causing pancreatitis are unknown, pancreatitis is commonly described as the autodigestion of the pancreas.
A patient returns to the floor after a laparoscopic cholecystectomy. The nurse should assess the patient for signs and symptoms of what serious potential complication of this surgery? Bile duct injury
The most serious complication after laparoscopic cholecystectomy is a bile duct injury.
A nurse is providing education to a patient who has undergone a laparoscopic cholecystectomy. During the immediate recovery period, the nurse should recommend what foods?
The nurse encourages the patient to eat a diet that is low in fats and high in carbohydrates and proteins immediately after surgery.
A previously healthy adult's sudden and precipitous decline in health has been attributed to fulminant hepatic failure, and the patient has been admitted to the intensive care unit.
The nurse should be aware that the treatment of choice for this patient is what? Liver transplantation
A patient's health decline necessitates the use of total parenteral nutrition. The patient has questioned the need for insertion of a central venous catheter, expressing a preference for a "normal IV."
The nurse should know that peripheral administration of high-concentration PN formulas is contraindicated because of the risk for what complication? Chemical phlebitis
A patient has been experiencing disconcerting GI symptoms that have been worsening in severity. Following medical assessment, the patient has been diagnosed with lactose intolerance.
The nurse should recognize an increased need for what form of health promotion? Frequent screening for osteoporosis
A nurse is working with a patient who is learning to care for a continent ileostomy (Kock pouch). Following the initial period of healing, the nurse is teaching the patient how to independently empty the ileostomy.
The nurse should teach the patient to do which of the following actions? Insert the catheter approximately 5 cm into the pouch.
A nurse is planning discharge teaching for a 21-year-old patient with a new diagnosis of ulcerative colitis. When planning family assessment, the nurse should recognize that which of the following factors
will likely have the greatest impact on the patient's coping after discharge? The family's ability to provide emotional support
patient has been diagnosed with acute pancreatitis. nurse is addressing the diagnosis of Acute Pain Related to Pancreatitis. What pharmacologic intervention is most likely to be ordered for this patient? IV hydromorphone
The pain of acute pancreatitis is often very severe and pain relief may require parenteral opioids such as morphine, fentanyl Sublimaze, or hydromorphone Dilaudid.
By the time symptoms occur in chronic pancreatitis, approximately 90% of normal acinar cell function exocrine function has been lost. Late detection is not usually attributable to the vagueness of symptoms.
The pancreas contributes continually to homeostasis and other organs are unable to perform its physiologic functions.
A patient who has undergone liver transplantation is ready to be discharged home. Which outcome of health education should the nurse prioritize?
The patient will take immunosuppressive agents as required.
A patient with pancreatic cancer has been scheduled for a pancreaticoduodenectomy (Whipple procedure). During education, patient should be informed that this procedure will involve the removal of which of the following?
This procedure involves removal of the gallbladder, a portion of the stomach, duodenum, proximal jejunum, head of the pancreas, and distal common bile duct. The rectum is not affected.
A nurse is caring for a patient who has a gastrointestinal tube in place. Which of the following are indications for gastrointestinal intubation? Select all that apply.
To remove gas from the stomach, To remove toxins from the stomach, To diagnose GI motility disorders
A patient admitted with inflammatory bowel disease asks the nurse for help with menu selections. What menu selection is most likely the best choice for this patient?
Tofu
nurse is caring for a patient with gallstones who has been prescribed ursodeoxycholic acid.patient asks how this medicine is going to help his symptoms. The nurse should be aware of what aspect of this drug's pharmacodynamics?
UDCA acts by inhibiting the synthesis and secretion of cholesterol, thereby desaturating bile.
A nurse is creating a care plan for a patient with a nasogastric tube. How should the nurse direct other members of the care team to check correct placement of the tube?
Use a combination of at least two accepted methods for confirming placement.
A 55-year-old female patient with hepatocellular carcinoma (HCC) is undergoing radiofrequency ablation. The nurse should recognize what goal of this treatment? Destruction of the patient's liver tumor
Using radio-frequency ablation, a tumor up to 5 cm in size can be destroyed in one treatment session.
patient with esophageal varices is being cared. varices have begun to bleed and the patient is at risk for hypovolemia. patient has Ringer's lactate at 150 cc/hr infusing. nurse might expect to maintain volume for this patient?
Volume expanders Because patients with bleeding esophageal varices have intravascular volume depletion and are subject to electrolyte imbalance, IV fluids with electrolytes and volume expanders are provided to restore fluid volume and replace electrolytes
A patient is postoperative day 1 following gastrostomy. The nurse is planning interventions to address the nursing diagnosis of Risk for Infection Related to Presence of Wound and Tube. What intervention is most appropriate?
Wash the area around the tube with soap and water daily.
A patient with a diagnosis of colon cancer is 2 days postoperative following bowel resection and anastomosis. The nurse has planned the patient's care in the knowledge of potential complications.
What assessment should the nurse prioritize? Frequent abdominal auscultation
An older adult has a diagnosis of Alzheimer's disease and has recently been experiencing fecal incontinence. However, the nurse has observed no recent change in the character of the patient's stools.
What is the nurse's most appropriate intervention? Toilet the patient on a frequent, scheduled basis.
A patient's colorectal cancer has necessitated a hemicolectomy with the creation of a colostomy. In the 4 days since the surgery, the patient has been unwilling to look at the ostomy or participate in any aspects of ostomy care.
What is the nurse's most appropriate response to this observation? Acknowledge the patient's reluctance and initiate discussion of the factors underlying it.
A nurse caring for a patient with a newly created ileostomy assesses the patient and notes that the patient has had not ostomy output for the past 12 hours. The patient also complains of worsening nausea.
What is the nurse's priority action? Report signs and symptoms of obstruction to the physician.
A patient has been experiencing occasional episodes of constipation and has been unable to achieve consistent relief by increasing physical activity and improving his diet.
What pharmacologic intervention should the nurse recommend to the patient for ongoing use? Psyllium hydrophilic mucilloid Metamucil
A patient is admitted to the unit with acute cholecystitis. physician noted that surgery will be scheduled in 4 days. patient asks why the surgery is being put off for a week when he has a "sick gallbladder."
What rationale would underlie the nurse's response? Surgery is delayed until the acute symptoms subside Unless the patient's condition deteriorates, surgical intervention is delayed until the acute symptoms subside
nurse is talking with a patient who is scheduled to have a hemicolectomy with the creation of a colostomy. patient admits to being anxious, and has many questions concerning the surgery, the care of a stoma, and necessary lifestyle changes.
Which of the following nursing actions is most appropriate? Maintain an open dialogue with the patient and facilitate a referral to the wound-ostomy-continence (WOC) nurse.
A patient has been admitted to the hospital for the treatment of chronic pancreatitis. The patient has been stabilized and the nurse is now planning health promotion and educational interventions.
Which of the following should the nurse prioritize? Educating the patient about postdischarge lifestyle modifications
A nurse is providing care for a patient with a diagnosis of late-stage Alzheimer's disease. The patient has just returned to the medical unit to begin supplemental feedings through an NG tube.
Which of the nurse's assessments addresses this patient's most significant potential complication of feeding? Frequent lung auscultation .
A patient is being treated on the acute medical unit for acute pancreatitis. The nurse has identified a diagnosis of Ineffective Breathing Pattern Related to Pain. What intervention should the nurse perform in order to best
address this diagnosis? The nurse maintains the patient in a semi-Fowler's position to decrease pressure on the diaphragm by a distended abdomen and to increase respiratory expansion.
A participant in a health fair has asked the nurse about the role of drugs in liver disease. What health promotion teaching has the most potential to prevent drug-induced hepatitis?Adhere to dosing recommendations of OTC
analgesics.Although any medication can affect liver function, use of acetaminophen found in many over-the-counter medications used to treat fever and pain has been identified as the leading cause of acute liver failure.
A patient with chronic pancreatitis had a pancreaticojejunostomy created 3 months ago for relief of pain and to restore drainage of pancreatic secretions. The patient has come to the office for a routine postsurgical
appointment. The patient is frustrated that the pain has not decreased. What is the most appropriate initial response by the nurse?
A patient is admitted to the ICU with acute pancreatitis. The patient's family asks what causes acute pancreatitis. The critical care nurse knows that a majority of patients with acute pancreatitis have what? Undiagnosed
chronic pancreatitis 80 % of patients with acute pancreatitis have biliary tract disease or a history of long-term alcohol abuse. patients usually have had undiagnosed chronic pancreatitis before their first episode
patient has undergone a laparoscopic cholecystectomy and is being prepared for discharge home. When providing health education, nurse should prioritize which of the following topics? Signs and symptoms of intra-abdominal
complications Because of the early discharge following laparoscopic cholecystectomy, the patient needs thorough education in the signs and symptoms of complications.
nurse is creating a care plan for a patient with acute pancreatitis. The plan includes reduced activity. What rationale for this intervention should be cited in the care plan? Bed rest lowers the metabolic rate and reduces
enzyme production.The acutely ill patient is maintained on bed rest to decrease the metabolic rate and reduce the secretion of pancreatic and gastric enzymes.
group of nurses have attended an inservice on the prevention of occupationally acquired diseases that affect healthcare providers. What action has the greatest potential to reduce the risk of acquiring Hep. C
in the workplace?Disposing of sharps appropriately and not recapping needles
A patient has been treated in the hospital for an episode of acute pancreatitis. The patient has acknowledged the role that his alcohol use played in the development of his health problem, but has not expressed specific plans for
lifestyle changes after discharge. What is the nurse's most appropriate response? Encourage the patient to connect with a community-based support group. Referral to A A as appropriate or other support groups is essential.
A patient with a diagnosis of esophageal varices has undergone endoscopy to gauge the progression of this complication of liver disease. Following the completion of this diagnostic test, what
nursing intervention should the nurse perform? Keep patient NPO until the patient's gag reflex returns.
A nurse has entered the room of a patient with cirrhosis and found the patient on the floor. The patient states that she fell when transferring to the commode. The patient's vital signs are within reference ranges and the nurse
observes no apparent injuries. What is the nurse's most appropriate action? Have the patient assessed by the physician due to the risk of internal bleeding.
A 37-year-old male patient presents at the ED complaining of nausea and vomiting and severe abdominal pain. The patient's abdomen is rigid, and there is bruising to the patient's flank. The patient's wife states that he was
on a drinking binge for the past 2 days. The ED nurse should assist in assessing the patient for what health problem? Severe pancreatitis with possible peritonitis
A patient admitted with acute diverticulitis has experienced a sudden increase in temperature and complains of a sudden onset of exquisite abdominal tenderness. The nurse's rapid assessment reveals that the
patient's abdomen is uncharacteristically rigid on palpation. What is the nurse's best response? Contact the primary care provider promptly and report these signs of perforation.
A nurse is preparing to provide care for a patient whose exacerbation of ulcerative colitis has required hospital admission. During an exacerbation of this health problem, the nurse would anticipate that the
patient's stools will have what characteristics? Watery with blood and mucus
A home health nurse is caring for a patient discharged home after pancreatic surgery. The nurse documents the nursing diagnosis Risk for Imbalanced Nutrition: Less than Body Requirements on the care plan based on the
potential complications that may occur after surgery. What are the most likely complications for the patient who has had pancreatic surgery? Malabsorption and hyperglycemia
A nurse is caring for a patient with cancer of the liver whose condition has required the insertion of a percutaneous biliary drainage system. The nurse's most
recent assessment reveals the presence of dark green fluid in the collection container. What is the nurse's best response to this assessment finding? Document the presence of normal bile output.
A patient has had a laparoscopic cholecystectomy. The patient is now complaining of right shoulder pain. What should the nurse suggest to relieve the pain? Application of heat 15 to 20 minutes each hour pain occurs in the right
shoulder or scapular area from migration of the CO2 used to insufflate the abdominal cavity during the procedure, nurse may recommend a heating pad for 15 to 20 minutes hourly, walking, and sitting up when in bed.
The nurse is caring for a patient suspected of having renal dysfunction. When reviewing laboratory results for this patient, the nurse recalls that several substances are filtered from the blood by the glomerulus and these
substances are then excreted in the urine. The nurse identifies the presence of which substances in the urine as abnormal findings? Blood cells and protein
patient with a cholelithiasis has been scheduled for a laparoscopic cholecystectomy. laparoscopic cholecystectomy is preferred by surgeons over an open procedure? Laparoscopic cholecystectomy poses fewer
surgical risks than an open procedure.Open surgery has largely been replaced by laparoscopic cholecystectomy removal of the gallbladder through a small incision through the umbilicus.
A nurse is caring for a patient with liver failure and is performing an assessment in the knowledge of the patient's increased risk of bleeding. The nurse recognizes that this risk is related to the patient's inability to
synthesize prothrombin in the liver. What factor most likely contributes to this loss of function? Inability of the liver to use vitamin K
A local public health nurse is informed that a cook in a local restaurant has been diagnosed with hepatitis A. What should the nurse advise individuals to obtain who ate at this restaurant and have never received
the hepatitis A vaccine? An immune globulin injection
A 16-year-old presents at the emergency department complaining of right lower quadrant pain and is subsequently diagnosed with appendicitis. When planning this patient's nursing care,
the nurse should prioritize what nursing diagnosis? Risk for Infection Related to Possible Rupture of Appendix
The nurse is caring for a patient who is undergoing diagnostic testing for suspected malabsorption. When taking this patient's health history and performing the physical assessment,
the nurse should recognize what finding as most consistent with this diagnosis? Foul-smelling diarrhea that contains fat
A patient has just been diagnosed with chronic pancreatitis. The patient is underweight and in severe pain and diagnostic testing indicates that over 80% of the patient's pancreas has been destroyed. The patient asks
the nurse why the diagnosis was not made earlier in the disease process. What would be the nurse's best response? "Chronic pancreatitis often goes undetected until a large majority of pancreatic function is lost."
A patient who suffered a stroke had an NG tube inserted to facilitate feeding shortly after admission. The patient has since become comatose and the patient's family asks
the nurse why the physician is recommending the removal of the patient's NG tube and the insertion of a gastrostomy tube. What is the nurse's best response? Regurgitation and aspiration are less likely.
A nurse is caring for a patient who has been scheduled for endoscopic retrograde cholangiopancreatography (ERCP) the following day. When providing anticipatory guidance for this patient, the nurse should describe what aspect of
this diagnostic procedure? The use of moderate sedation
patient has developed hepatic encephalopathy secondary to cirrhosis and is receiving care the patient's current medication regimen includes lactulose Cephulac 4 times daily. What desired outcome should the nurse relate
to this pharmacologic intervention? Two to 3 soft bowel movements daily Lactulose (Cephulac) is administered to reduce serum ammonia levels.
A patient with gallstones has been prescribed ursodeoxycholic acid (UDCA). The nurse understands that additional teaching is needed regarding this medication when the patient states: "I will take this medication for 2
weeks and then gradually stop taking it." Ursodeoxycholic acid (UDCA) has been used to dissolve small, radiolucent gallstones composed primarily of cholesterol. This drug can reduce the size of existing
