Metabolic Elimination Passpoint quizz
A client who had an open cholecystectomy 2 days ago reports pain in the right calf. What is the nurse's priority intervention? Assess the leg for swelling and redness Instruct the client to flex the knee and hip Apply a warm compress and call the health care provider Gently massage the calf and notify the health care provider
Assess the leg for swelling and redness
The nurse is explaining to a client the difference between hemodialysis and continuous renal replacement therapy (CRRT). What statement by the client leads the nurse to determine that additional education is needed? "CRRT is faster than hemodialysis." "CRRT is used to treat acute kidney injury." "CRRT is used for hemodynamically unstable clients." "CRRT causes less electrolyte changes."
"CRRT is faster than hemodialysis"
The charge nurse is working on a medical-surgical unit and must rearrange room assignments for several clients. Which clients should the nurse put in the same room? Select all that apply. a client with intractable vomiting and diarrhea a client who underwent cholecystectomy today a client with pain related to pancreatitis a client with colon cancer who is receiving chemotherapy a client with suspected tuberculosis (TB)
A client with pain related to pancreatitis A client who underwent cholecystectomy today
PROGRESS NOTES: Skin warm and dry. Color pink with no signs of pallor. BP 156/84, HR 102/min, RR 22/min. O2 at 2 l/min via nasal cannula. O2 saturation 98%. Denies any shortness of breath. Bowel sounds present in all four quadrants. Patient states he has pain-rated at 8 on pain scale of 0-10. NG tube to low intermittent suction- light green drainage present. NG tube placement verified; pH of 3. Periumbilical area appears discolored and ecchymotic. A client has been hospitalized with pancreatitis for 3 days. The nurse assesses the client and documents the accompanying results. The nurse realizes these findings are a manifestation of what sign? Cullen's sign Chvostek's sign Trousseau's sign Broca's sign
Cullen's sign
At 0800, the nurse reviews the amount of T-tube drainage for a client who underwent an open cholecystectomy yesterday. After reviewing the output record (see chart), what should the nurse do next? Report the 24-hour drainage amount at 12 noon. Clamp the t-tube. Evaluate the tube for patency. Irrigate the t-tube.
Evaluate the tube for patency
A nurse is assessing a client who has a potential diagnosis of pancreatitis. Which risk factors predispose the client to pancreatitis? Select all that apply. excessive alcohol use gallstones abdominal trauma hypertension hyperlipidemia with excessive triglycerides hypothyroidism
Excessive alcohol use Gallstones Abdominal trauma Hyperlipidemia with excessive triglycerides
When the nurse is providing care for a client hospitalized with acute pancreatitis who has severe abdominal pain, which nursing interventions would be most appropriate for this client? Select all that apply. Place the client in a side-lying position. Administer morphine sulfate for pain as needed. Maintain the client on a high-calorie, high-protein diet. Monitor the client's respiratory status. Obtain daily weights.
Place the client in a side-lying position Administer morphine sulfate for pain as needed Monitor the client's respiratory status Obtain daily weights
A client has had an incisional cholecystectomy. Which of the following nursing interventions has the highest priority in postoperative care for this client? Using incentive spirometry every 2 hours while awake Performing leg exercises every shift Maintaining a weight-reduction diet Promoting incisional healing
Using incentive spirometry every 2 hours while awake
Which nursing action is most appropriate for a client hospitalized with acute pancreatitis? withholding all oral intake, as ordered, to decrease pancreatic secretions administering oral pain medications, as ordered, to relieve severe pain limiting I.V. fluids, as ordered, to decrease cardiac workload keeping the client supine to increase comfort
Withholding all oral intake, as ordered, to decrease pancreatic secretions
A client is scheduled for a laparoscopic cholecystectomy and is surprised to learn that they will be discharged later the same day, provided there are no complications. When caring for a client who will be discharged shortly after a procedure, the nurse must ensure that health education is begun as early as possible. ensure that this is specified in the client's informed consent document. administer prophylactic antibiotics four to six hours prior to surgery. ensure that the client is safe to drive before being discharged.
ensure that the health education is begun as early as possible
A client is admitted with acute pancreatitis. The nurse should monitor which laboratory values? decreased urine amylase level increased calcium level decreased glucose level increased serum amylase and lipase levels
increased serum amylase and lipase levels
The nurse should monitor the client with acute pancreatitis for which complication? heart failure duodenal ulcer cirrhosis pneumonia
pneumonia
A client with pancreatitis returns from an endoscopic retrograde cholangiopancreatography (ERCP). Which assessment would be of most concern to the nurse? reports of upper abdominal pain reports of a sore throat retrograde amnesia poor gag reflex
poor gag reflex
Which symptom would the nurse most likely observe in a client with cholecystitis from cholelithiasis? Black stools Nausea after ingestion of high-fat foods Elevated temperature of 103 Decreased white blood cell count
Nausea after ingestion of high-fat foods
The nurse is caring for a 3-year-old child with acute kidney injury. Which laboratory finding should the nurse immediately report to the healthcare provider? potassium level of 6.5 mEq/L (6.5 mmol/L) creatinine 2.5 mg/dL (221 umol/L) sodium 130 mEq/L (130 mmol/L) blood urea nitrogen (BUN) 40 mg/dL (urea 14.3 mmol/L)
potassium level of 6.5 mEq/L (6.5 mmol/L)
A client undergoes a laparoscopic cholecystectomy. Which instructions should the nurse give the client about a diet immediately after surgery? "You can't eat or drink anything for 24 hours" "You may resume your normal diet the day after your surgery" "Start with liquids and see how you feel" "You can progress from a liquid to a bland diet as tolerated"
"Start with liquids and see how you feel"
Which nursing measure would be most effective in helping the client cough and deep breathe after a cholecystectomy? Have the client take rapid, shallow breaths to decrease pain Have the client lay on the left side while coughing and deep breathing Teach the client to use a folded blanket or pillow to splint the incision Withhold pain medication so the client can be alert enough to follow the nurse's instructions
Teach the client to use a folded blanket or pillow to splint the incision
PROGRESS NOTES: Client admitted to the emergency department with severe upper quadrant pain radiating to the back, nausea and vomiting, and fever. Laboratory results received via telephone as follows: glucose 462 mg/dL, WBC 14,000 cells/mm, lipase 214 units/L and calcium 6.5 mg/dL A client has been admitted to the emergency department with severe mid-epigastric, upper quadrant abdominal pain. Based on the signs and symptoms and laboratory data documented in the chart, the nurse would anticipate preparing for which diagnosis? Peptic ulcer Crohn's disease Pancreatitis Irritable bowel syndrome
pancreatitis