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The client with obstructive jaundice asks the nurse why his skin is so itchy. Which is the nurse's best response? a. "Bile salts accumulate in the skin and cause the itching." b. "Toxins released from an inflamed gallbladder lead to itching." c. "Itching is caused by the release of calcium into the skin." d. "Itching is caused by a hypersensitivity reaction."
ANS: A In obstructive jaundice, the normal flow of bile into the duodenum is blocked, allowing excess bile salts to accumulate on the skin. This leads to itching, or pruritus. The other statements are not accurate.
A client is hospitalized with acute pancreatitis. The nursing assistant reports to the nurse that when a blood pressure cuff was applied, the client's hand had a spasm. Which additional finding does the nurse correlate with this condition? a. Serum calcium, 5.8 mg/dL b. Serum sodium, 166 mEq/L c. Serum creatinine, 0.9 mg/dL d. Serum potassium, 4.2 mEq/dL
ANS: A Spasm of the hand when a blood pressure cuff is applied (Trousseau's sign) is indicative of hypocalcemia. The client's calcium level is low. The sodium level is high, but that is not related to Trousseau's sign. Creatinine and potassium levels are normal.
The nurse is caring for a client with end-stage pancreatic cancer. The client asks the nurse, "Why is this happening to me?" Which is the nurse's best response? a. "I don't know. I wish I had an answer for you, but I don't." b. "It's important to keep a positive attitude for your family right now." c. "Scientists have not determined why cancer develops in certain people." d. "I think that this is a trial so you can become a better person because of it."
ANS: A The client is not asking the nurse actually to explain why the cancer has occurred, but simply to validate that no easy or straightforward answer can be found.
The nurse is caring for a postoperative client who reports pain in the shoulder blades following laparoscopic cholecystectomy surgery. Which direction does the nurse give to the nursing assistant to help relieve the client's pain? a. "Ambulate the client in the hallway." b. "Apply a cold compress to the client's back." c. "Encourage the client to take sips of hot tea or broth." d. "Remind the client to cough and deep breathe every hour.
ANS: A The client who has undergone a laparoscopic cholecystectomy may report free air pain because of retention of carbon dioxide in the abdomen. The nurse assists the client with early ambulation to promote absorption of the carbon dioxide. Coughing and deep breathing are important postoperative activities, but they are not related to discomfort from carbon dioxide. Cold compresses and drinking tea would not be helpful.
The postanesthesia care unit nurse is caring for a client who has just undergone an open Whipple procedure. The client has multiple tubes and drains in place after the surgery. Which does the nurse assess first? a. Endotracheal tube with 40% fraction of inspired oxygen (FiO2) b. Foley catheter to bedside drainage c. Nasogastric tube to low intermittent suction d. Triple-lumen IV catheter with lactated Ringer's solution
ANS: A Using the ABCs, airway and oxygenation status should always be assessed first. Next, the nurse should assess the IV line (circulation). After that, the other two items can be assessed.
The nurse is caring for a female client with cholelithiasis. Which assessment findings from the client's history and physical examination may have contributed to development of the condition? (Select all that apply.) a. Body mass index (BMI) of 46 b. Vegetarian diet c. Drinking 4 ounces of red wine nightly d. Pregnant with twins e. History of metabolic syndrome f. Glycosylated hemoglobin level of 15%
ANS: A, D, F Obesity, pregnancy, and diabetes are all risk factors for the development of cholelithiasis. Moderate alcohol intake and a diet low in saturated fats may decrease the risk. Metabolic syndrome is a precursor to diabetes, and the client should be informed of the connection.
The nurse is caring for a client with chronic pancreatitis. Which instruction by the nurse is most appropriate? a. "You will need to limit your protein intake." b. "We need to call the dietitian to get help in planning your diet." c. "You cannot eat concentrated sweets any longer." d. "Try to eat less red meat and more chicken and fish."
ANS: B A client with chronic pancreatitis needs 4000 to 6000 calories per day for optimum nutrition and healing. The client may have additional restrictions if he or she has other health problems such as diabetes. The nurse should collaborate with the registered dietitian to help the client plan nutritional intake.
The nurse is providing discharge teaching for a client who has just undergone laparoscopic cholecystectomy surgery. Which statement by the client indicates understanding of the instructions? a. "I will drink at least 2 liters of fluid a day." b. "I need a diet without a lot of fatty foods." c. "I should drink fluids between meals rather than with meals." d. "I will avoid concentrated sweets and simple carbohydrates."
ANS: B After cholecystectomy, clients need a nutritious diet without a lot of excess fat; otherwise a special diet is not recommended for most clients. Good fluid intake is healthy for all people but is not related to the surgery. Drinking fluids between meals helps with dumping syndrome, which is not seen with this operation. Restriction of sweets is not required.
A client is admitted for suspected cholecystitis. On reviewing laboratory results, the nurse notes that the client's amylase is elevated. Which action by the nurse is best? a. Document the finding in the chart. b. Ask the client about drinking habits. c. Notify the health care provider. d. Place the client on clear liquids.
ANS: B Serum and urine amylase levels are elevated when the pancreas becomes inflamed. One cause of pancreatitis is gallbladder disease; another causative factor is alcohol intake. The nurse should tactfully explore this subject with the client before documenting the findings and notifying the provider. The client may need to be NPO or on clear liquids, but the nurse does not have enough information yet to determine this.
The nurse is caring for a client with acute pancreatitis. Which nursing intervention best reduces discomfort for the client? a. Administering morphine sulfate IV every 4 to 6 hours as needed b. Maintaining NPO status for the client with IV fluids c. Providing small, frequent feedings, with no concentrated sweets d. Placing the client in semi-Fowler's position at elevation of 30 degrees
ANS: B The client should be kept NPO to reduce GI activity and reduce pancreatic enzyme production. IV fluids should be used to prevent dehydration. The client may need a nasogastric (NG) tube. Pain medications should be given around the clock and more frequently than every 4 to 6 hours. A fetal position with legs drawn up to the chest will promote comfort.
The nurse is caring for a client who is being discharged from the hospital after an attack of acute pancreatitis. Which discharge instructions does the nurse provide for the client to help prevent a recurrence? (Select all that apply.) a. "Take a 20-minute walk at least 5 days each week." b. "Attend local Alcoholics Anonymous (AA) meetings weekly." c. "Choose whole grains rather than foods with simple sugars." d. "Use cooking spray when you cook rather than margarine or butter." e. "Stay away from milk and dairy products that contain lactose." f. "We can talk to your doctor about a prescription for nicotine patches."
ANS: B, D, F The client should be advised to stay sober, and AA is a great resource. The client requires a low-fat diet, and cooking spray is low in fat compared with butter or margarine. If the client smokes, he or she must stop because nicotine can precipitate an exacerbation. A nicotine patch may help the client quit smoking. The client must rest until his or her strength returns. The client requires high carbohydrates and calories for healing; complex carbohydrates are not preferred over simple ones. Dairy products do not cause a problem.
The nurse is caring for a client who had a T-tube placed 3 days ago. Which assessment finding indicates to the nurse that the procedure was successful? a. Sclera that is slightly icteric b. Positive Blumberg's sign c. Soft, brown, formed stool this morning d. Sips of clear liquid tolerated without nausea
ANS: C A transhepatic biliary catheter (T-tube) decompresses extrahepatic ducts to promote the flow of bile. When bile flows normally, it reaches the large intestine, where bile is converted to urobilinogen, coloring the stools brown. The other findings would not indicate successful T-tube placement.
The nurse is caring for a client who has just undergone traditional cholecystectomy surgery and has a Jackson-Pratt (JP) drain in place. The nurse notes serosanguineous drainage present in the drain. Which is the nurse's priority action? a. Gently milk the drain tubing. b. Notify the surgeon immediately. c. Document the finding in the client's chart. d. Irrigate the drain with sterile normal saline.
ANS: C Drainage from the JP drain initially appears serosanguineous in color. The drainage will appear bile-colored within 24 hours. The nurse does not need to notify the surgeon, milk the tubing, or irrigate the drain because this is an expected finding.
The nurse is providing discharge teaching for a client who will be receiving pancreatic enzyme replacement at home. Which statement by the client indicates that additional teaching is needed? a. "The capsules can be opened and the powder sprinkled on applesauce if needed." b. "I will wipe my lips carefully after I drink the enzyme preparation." c. "The best time to take the enzymes is immediately after I have a meal or a snack." d. "I will not mix the enzyme powder with food or liquids that contain protein."
ANS: C The enzymes should be taken immediately before eating meals or snacks. The client should wipe his or her lips carefully after drinking the enzyme preparation because the liquid could damage the skin. If the client cannot swallow the capsules whole, they can be opened up and the powder sprinkled on applesauce, mashed fruit, or rice cereal. Protein items will be dissolved by the enzymes if they are mixed together.
The nurse is caring for a client with acute pancreatitis. During the physical assessment, the nurse notes a grayish-blue discoloration of the client's flanks. Which is the nurse's priority action? a. Prepare the client for emergency surgery. b. Place the client in high Fowler's position. c. Insert a nasogastric (NG) tube to low intermittent suction. d. Ensure that the client has a patent large-bore IV site.
ANS: D Grayish-blue discoloration on the flanks (Turner's sign) indicates pancreatic enzyme leakage into the peritoneal cavity. This presents a risk of shock for the client, so IV access should be maintained with at least one large-bore patent IV catheter. The client may or may not need surgery; usually a fetal position helps with pain, and having an NG tube would not take priority over IV access.
The nurse is providing discharge teaching for a client who will be going home with a T-tube following cholecystectomy surgery. Which statement by the client indicates the need for additional teaching? a. "I will keep the drainage bag lower than the tube itself." b. "I will inspect the T-tube drainage site daily for signs of infection." c. "I will be careful not to pull on the tube or to accidentally pull it out." d. "I will slowly pull about an inch of the tube out each day until it's out."
ANS: D The provider will discontinue the T-tube. The other statements are accurate.
The nurse is caring for a client with acute pancreatitis. The client's health care provider has ordered gentamicin (Garamycin) 3 mg/kg/day in three divided doses. The client weighs 264 lb. The client will receive _______ milligrams/dose of Garamycin.
ANS: 120 264 lb/(2.2 lb/kg) = 120 kg (3 mg/kg/day) 120 kg = 360 mg/day (360 mg/day)/3 = 120 mg/dose
The nurse is caring for a client who has undergone surgery to drain a pancreatic pseudocyst with placement of a pancreatic drainage tube. Which nursing intervention prevents complications from this procedure? a. Positioning the client in a right side-lying position b. Applying a skin barrier around the drainage tube site c. Clamping the drainage tube for 2 hours every 12 hours d. Irrigating the drainage tube daily with 30 mL of sterile normal saline
ANS: B The nurse assesses the skin around the drainage tube for redness or skin irritation, which can be severe from leakage of pancreatic enzymes. The nurse applies a skin barrier such as Stomahesive around the drainage tube to prevent excoriation. A side-lying position may be more comfortable for the client. The drainage tube should not be clamped or irrigated without specific orders.
The nurse is caring for a client after a Whipple procedure. Which manifestations might indicate that a complication from the operation has occurred? (Select all that apply.) a. Urinary retention b. Substernal chest pain c. Shortness of breath d. Lack of bowel sounds or flatus e. Urine output of 20 mL/6 hr
ANS: B, C, D, E Myocardial infarction (chest pain), pulmonary embolism (shortness of breath), adynamic ileus (lack of bowel sounds or flatus), and renal failure (urine output of 20 mL/6 hr) are just some of the complications that the nurse must monitor the client for after the Whipple procedure. Urinary retention is not a complication of this operation.
The nurse is caring for a client who has just been diagnosed with end-stage pancreatic cancer. The nurse assesses the client's emotional response to the diagnosis. Which is the nurse's initial action for the assessment? a. Bring the client to a quiet room for privacy. b. Pull up a chair and sit next to the client's bed. c. Determine whether the client feels like talking about his or her feelings. d. Review the health care provider's notes about the prognosis for the client.
ANS: C Before conducting an assessment about the client's feelings, the nurse should determine whether he or she is willing and able to talk about them. If the client is open to the conversation and his or her room is not appropriate, an alternative meeting space may be located. The nurse should be present for the client during this time, and pulling up a chair and sitting with the client indicates that presence. Because the nurse is assessing the client's response to a terminal diagnosis, it is not necessary to have detailed information about the projected prognosis; the nurse knows that the client is facing an end-of-life illness.
The nurse is caring for a client who had undergone a Whipple procedure 2 days previously. The nurse notes that the client's hands and feet are edematous, and urine output has decreased from the previous day. Which intervention does the nurse expect to provide for the client? a. Increase the client's IV fluid infusion rate. b. Monitor the client's blood sugar level every 4 hours. c. Add colloids to the client's IV solutions. d. Reinsert the client's nasogastric (NG) tube.
ANS: C Edema and low urine output following the Whipple procedure most likely are caused by hypoalbuminemia. Low albumin leads to third spacing of fluids and decreased intravascular fluids. As a result, edema and low urine output develop. Adding a colloid solution to the client's IV regimen will help shift edematous fluid from the interstitial space back into the intravascular space. Increasing the client's IV infusion rate will worsen the edema unless additional protein is added. Blood glucose monitoring and NG tubes are not related to this problem.
The nurse is caring for a client with cholecystitis. Which assessment finding indicates to the nurse that the condition is chronic rather than acute? a. Abdomen that is hyperresonant to percussion b. Hyperactive bowel sounds and diarrhea c. Clay-colored stools and dark amber urine d. Rebound tenderness in the right upper quadrant
ANS: C In chronic cholecystitis, bile duct obstruction results in the absence of urobilinogen to color the stool. Excess circulating bilirubin turns the urine dark and foamy. The other assessment findings do not correlate with chronic cholecystitis.
The nurse is caring for a client with cholecystitis. The client is a poor historian and is unable to tell the nurse when the symptoms started. Which assessment finding indicates to the nurse that the condition is chronic rather than acute? a. Temperature of 100.1° F (37.8° C) b. Positive Murphy's sign c. Light-colored stools d. Upper abdominal pain after eating
ANS: C Jaundice, clay-colored stools, and dark urine are more commonly seen with chronic than with acute cholecystitis. The other symptoms are seen equally with both conditions.
The nurse is teaching a community group about pancreatic cancer. Which risk factor does the nurse instruct is known for development of this type of cancer? a. Hypothyroidism b. Cholelithiasis c. BRCA2 gene mutation d. African-American ethnicity
ANS: C Mutations in both BRCA2 and p16 genes increase the risk for developing pancreatic cancer in a small number of cases. The other factors do not appear to be linked to increased risk.
The nurse is teaching a client with a history of cholelithiasis to select menu items for dinner. Which selections made by the client indicate that the nurse's teaching was effective? a. Lasagna, tossed salad with Italian dressing, 2% milk b. Grilled cheese sandwich, tomato soup, coffee with cream c. Caesar salad with chicken, soft breadstick with butter, diet cola d. Roasted chicken breast, baked potato with chives, hot tea with sugar
ANS: D Clients with cholelithiasis should avoid foods high in fat and cholesterol, such as whole milk, butter, and fried foods. Lasagna, 2% milk, grilled cheese, cream, and butter all have high levels of fat. The meal with the least amount of fat is the chicken breast dinner.