RNSG 2539 Exam 2
What is the normal range of fibrin degradation products (FDPs)?
- 0-5 mcg/ mL
What is normal range of Fibrinogen?
- 170-340 mg/ dL (decreases in DIC)
What is normal range for thrombin time (TT)?
- 8-11 seconds (clot formation)
What is examples of a fibrinolytic inhibitor?
- Aminocaproic Acid
If a PT has an allergic reaction to Heparin, what drug would be administered as treatment?
- Lepirudin (refludan)
What is the normal range for PT?
-11 - 12.5 seconds (extrinsic pathway) think (PET)
What is the normal range for platelet count?
-150,000-450,000/ mm^3 (decrease w/ DIC)
What is the normal range for aPTT?
-23-35 seconds (intrinsic pathway) think PItt?
What are some obstetric conditions that have been associated with DIC?
-Abrupito placentratae -Dead fetus syndrome -Pre-eclampsia & eclampsia -Amniotic fluid embolism
DIC can occur secondary to what type of conditions? Select all that apply:
-Abrupitoplacente -Amniotic fluid embolism -Endotoxin sepsis -Retained dead fetus -Post hemorrhage shock -Hydatidformmole -Gynecologic Malinganries
How does DIC initiate activation of the intrinsic pathway?
-Activated through extensive endothelial damage with activation of factor XII. This results from viruses, infections, immune mechanisms, stasis of blood or temperature extremes.
What are some infections associations with DIC?
-Acute bacterial infections (meningococal meningitis) -Histoplasmosis, Aspergicrosis -Ricketsial Infections (rocky mountain spotted fever) -Parasitic infections (malaria) -Sepsis/ Septic shock
The nurse is caring for a postpartum patient admitted to the intensive care unit with a diagnosis of disseminated intravascular coagulation (DIC). What is the drug of choice to treat this problem? A. Heparin B. Urokinase C. Aspirin D. Warfarin
A.) Heparin
A nurse is providing discharge education to a patient who has recently been diagnosed with a bleeding disorder. What topic should the nurse prioritize when teaching this patient? A) Avoiding buses, subways, and other crowded, public sites B) Avoiding activities that carry a risk for injury C) Keeping immunizations current D) Avoiding foods high in vitamin K
B) Avoiding activities that carry a risk for injury
When the nurse administers heparin it is anticipated the drug will have what action on the patient's body? A) Binds to factor X B) Blocks the formation of thrombin C) Binds to factor Xa D) Promotes the inactivation of factor VIII
B) Blocks the formation of thrombin
A patient has been diagnosed with acute pancreatitis. The nurse is addressing the diagnosis of Acute Pain Related to Pancreatitis. What pharmacologic intervention is most likely to be ordered for this patient? A) Oral oxycodone B) IV hydromorphone (Dilaudid) C) IM meperidine (Demerol) D) Oral naproxen (Aleve)
B) IV hydromorphone (Dilaudid)
A client has been admitted for immune thrombocytopenic purpura. The client has not responded to corticosteroid treatment. The priority nursing intervention for this client would include which of the following treatment measures? A) Place the client in isolation, so the skin rashes will not spread to other clients. B) Insert an intravenous catheter, so immune globulin can be administered in a timely manner. C) Insert a Foley catheter to monitor hourly urine output. D) Prepare a surgical permit for an emergency splenectomy.
B) Insert an intravenous catheter, so immune globulin can be administered in a timely manner.
A nurse is providing care to a child with idiopathic thrombocytopenic purpura with a platelet count of 18,000/mm3. Which medication would the nurse most likely expect to be ordered? A) Folic acid B) Intravenous immune globulin C) Dimercaprol D) Deferoxamine
B) Intravenous immune globulin
A young man has been diagnosed with hemophilia and the nurse is planning his discharge teaching and includes what teaching point? A) Using nonsteroidal anti-inflammatory drugs (NSAIDs) for mild pain B) Preventing trauma to the body C) Receiving IV factor VIII therapy at home D) Understanding the condition is an X-linked recessive disorder
B) Preventing trauma to the body
What are some ways to combat DIC? Select all that apply:
-Anticoagulation therapy (low-molecular weight heparin) -Packed RBCs -Platelet concentrate -Antithrombin concentrate -Nonclotting Protein- containing volume will expand like: plasma protein fraction or albumin
What meds would be given for DIC?
-Anticoagulations such as unfractionated heparin or Lmw heparins sodium -Broad spectrum antibiotics for Gram-neg sepsis -O2 administration
What are some hematologic conditions associated with DIC?
-Blood Transfusions Reactions
What are some trauma signs that have been associated with DIC?
-Burns -Heatstroke -Massive traumas -Snake bite -Surgery including extracorpeal circulation?
What are 3 main causes of DIC?
-Burns -Sepsis -Abrupito placentae
What are some complications associated with DIC?
-Cardiac tamponade -Hemothorax -Stroke -MODs
DIC can be decreased as a loss of balance between what two activities?
-Clot forming activity of thrombin -Clot lysin activity of plasmin
What clinical manifestations of DIC are primarily involved?
-Compromise of organ function or failure -PT typically develop mods
What is the only manifestation of DIC during its initial process?
-Decrease in platelet count
How is bleeding characterized in DIC?
-Decreased Platelet count -Decreased fibrinogen levels -Prolonged PT, ApT (thrombiotic) -Increased Fibrinogen Degradation -Increased D-dimers
A patient with DIC is at a higher risk for what?
-Deficient fluid volume
What are some acute clinical manifestations of DIC?
-Directly related to bleeding problems such as: Petechia, Purpura, oozing from puncture sites or severe hemorrhaging.
What is the pathophysiology of DIC?
-Excess thrombin converts fibrinogen to fibrin, producing fibrin clots in the microcirculation
Increased levels of ____________, _______________, __________, and ________________ will be noted in DIC:
-Fibrinolycin, fibrinopeptide A, positive fibrin split products and D-dimers.
What are some pysical finding for DIC?
-Hematoria -Purpura, Jaundice -Taghycardia -Hemoptysic (coughing up blood) -XXXXXX (low urine output) -Dyspnea or tachypnea -Pleural friction rub -Confusion
What is the PT teaching for DIC?
-Include their family
How does Heparin work in the circulatory system?
-Inhibits thrombus and clot production by blocking the conversion of prothrombin to thrombin & fibrogen to fibrin.
What is the concept behind heparin for PT with DIC?
-It prevents the clotting phase from being completed which inhibits the breakdown of fibrinogen. - It also helps avoid hemorrhage by preventing the body from depleting entire stage of coagulation factors.
In DIC, microemboli may obstruct blood vessels and cause tissue hypoxia/ necrotic damage to which organ structures? Select all that apply:
-Kidneys -Heart -Lungs -Brain
What are some adverse effects of Heparin? Select all that apply:
-Loss of hair -Bruising -Chills -Fever -Osteoporosis -Suppression of renal function
What are some Cancers that have been associated with DIC ?
-Metastatic cancer -Acute leukemia
PT with Frank DIC typically bleed from where?
-Mucous Membranes -Venipuncture Sites -GI Urinary Tracts
Discharge planning for DIC?
-Multidisciplinary team -Primary discharge nurse -Care manager -Hematologist -PCP -Assess PT level of independence before admission -Document discharge planning evaluation in PT clinical record -Include who was present and involved in discharge planning
How does DIC initiate activation of the extrinsic pathway?
-Occurs with liberation of tissue factor and associated with obstetric complications, trauma, bacterial sepsis & cancer
What results are indicative of DIC?
-Platelet count less than 150,000/mL -Prothrombintine is more than 19 seconds -partial thromboplastin time is greater than 40 sec -D-dimer is positive at < 1:8 dilution -BUN is elevated to more than 25 mg/dL
What lab testing results are indicative of DIC?
-Prothrombin Time (PT) -partial throboplastin time (PTT) -Activated Partial Thrompoplastin Time (aPTT) -Bleeding Time -Thrombin Time Decrease levels: -Fibrogen -Platelets -Clotine factor II, V, VIII, & X and Antithrombin III
What is a common cause of DIC?
-Sepsis
What is risk factor associated with DIC?
-Sepsis -Cardiac Arrest -ARDs -DKA -PE -Sickle Cell Anemia -Liver failure
The treatment of DIC is directed toward managing what?
-The Primary disease -Replacing clotting components -Preventing further activation of clotting mechanisms
What other test for DIC can be pre-determined at bedside, can better assess platelet function?
-Thrombelastography
What are some potential therapies to DIC other than Heparin?
-Tissue factor pathway inhibitors, antithrombin, Protein C concentrates, & anti-inflammatory cytokines like INL-I
How does DIC happen in postpartum hemorrhaging?
-Tissue factors released from necrotic place/fetal tissue or amniotic fluid my enter the circulation, inciting DIC.
Why might cryotrecipitate be given?
-To replace fibrinogen & factors V & VII
How do you correct the clotting factor deficiency in DIC?
-Transition of FFP - " " platelets - " " fibrinogen containing cryoprecipitate
The increase with DiC is unknown but it occurs in 1%-2% of PT with 3.
1- 30%, 2-50%, 3-Sepsis
A patient with a recent diagnosis of ITP has asked the nurse why the care team has not chosen to administer platelets, stating, 'I have low platelets, so why not give me a transfusion of exactly what I'm missing?' How should the nurse best respond? A) 'Transfused platelets usually aren't beneficial because they're rapidly destroyed in the body.' B) 'A platelet transfusion often blunts your body's own production of platelets even further.' C) 'Finding a matching donor for a platelet transfusion is exceedingly difficult.' D) 'A very small percentage of the platelets in a transfusion are actually functional.'
A) 'Transfused platelets usually aren't beneficial because they're rapidly destroyed in the body.'
Which of the following individuals most likely faces the highest risk of developing chronic pancreatitis? A) A woman who has six to eight alcoholic beverages each evening B) A man who has become profoundly ill during a tropical vacation C) A woman who takes two Tylenol tablets five to six times a day D) An obese man who has a high-fat diet and has a sedentary lifestyle
A) A woman who has six to eight alcoholic beverages each evening
When explaining acute pancreatitis to a newly diagnosed client, the nurse will emphasize the pathogenesis begins with an inflammatory process whereby: A) Activated pancreatic enzymes escape into surrounding tissues, causing autodigestion of pancreatic tissue. B) The pancreas is irreversibly damaged and will not recover to normal functioning (chronic). C) The pancreas will hypertrophy (enlarge) to the point of causing bowel obstruction. D) Stones will develop in the common bile duct, resulting in acute jaundice.
A) Activated pancreatic enzymes escape into surrounding tissues, causing autodigestion of pancreatic tissue.
A 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 a nurse's risk of acquiring hepatitis C in the workplace? A) Disposing of sharps appropriately and not recapping needles B) Performing meticulous hand hygiene at the appropriate moments in care C) Adhering to the recommended schedule of immunizations D) Wearing an N95 mask when providing care for patients on airborne precautions
A) Disposing of sharps appropriately and not recapping needles
A healthy, primiparous (first-time) mother delivered a healthy infant several hours ago, but the mother has experienced postpartum hemorrhage. Which of the following disorders is most likely to underlie the client's excessive bleeding after delivery? A) Disseminated intravascular coagulation B) Hemophilia A C) Von Willebrand disease D) Thrombotic thrombocytopenic purpura (TTP)
A) Disseminated intravascular coagulation
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? A) Glucose tolerance test B) ERCP C) Pancreatic biopsy D) Abdominal ultrasonography
A) Glucose tolerance test
The results of a patient's most recent blood work and physical assessment are suggestive of immune thrombocytopenic purpura (ITP). This patient should undergo testing for which of the following potential causes? Select all that apply. A) Hepatitis B) Acute renal failure C) HIV D) Malignant melanoma E) Cholecystitis
A) Hepatitis C) HIV
A patient's assessment and diagnostic testing are suggestive of acute pancreatitis. When the nurse is performing the health interview, what assessment questions address likely etiologic factors? Select all that apply. A) How many alcoholic drinks do you typically consume in a week? B) Have you ever been tested for diabetes? C) Have you ever been diagnosed with gall stones? D) Would you say you eat a particularly high fat diet? E) Does anyone in your family have cystic fibrosis?
A) How many alcoholic drinks do you typically consume in a week? C) Have you ever been diagnosed with gall stones?
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. A) Immunization B) Use of standard precautions C) Consumption of a vitamin-rich diet D) Annual vitamin K injections E) Annual vitamin B12 injections
A) Immunization B) Use of standard precautions
A client with hepatitis B asks the nurse, "How did I get this hepatitis?" The nurse responds that the mode of transmission is predominantly by: Select all that apply. A) Intravenous drug use B) Fecal-oral route C) Unprotected sexual intercourse D) Sharing oral secretions by kissing E) Inhalation of airborne droplets
A) Intravenous drug use C) Unprotected sexual intercourse
The nurse is providing care to a child with pancreatitis. When reviewing the child's laboratory test results, which of the following would the nurse expect to find? Select all answers that apply. A) Leukocytosis B) Decreased C-reactive protein C) Elevated serum amylase levels D) Positive stool culture E) Decreased serum lipase levels
A) Leukocytosis C) Elevated serum amylase levels
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? A) Measure the patient's abdominal girth daily. B) Limit the use of opioid analgesics. C) Monitor the patient for signs of dysphagia. D) Encourage activity as tolerated.
A) Measure the patient's abdominal girth daily.
A 37-year-old man presents to the ED complaining of N/V 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? A) Severe pancreatitis with possible peritonitis B) Acute cholecystitis C) Chronic pancreatitis D) Acute appendicitis with possible perforation
A) Severe pancreatitis with possible peritonitis
A patient has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The patient's current medication regimen includes lactulose (Cephulac) four times daily. What desired outcome should the nurse relate to this pharmacologic intervention? A) Two to 3 soft bowel movements daily B) Significant increase in appetite and food intake C) Absence of nausea and vomiting D) Absence of blood or mucus in stool
A) Two to 3 soft bowel movements daily
The nurse is caring for a 12-year-old boy with idiopathic thrombocytopenia. The nurse is providing discharge instructions about home care and safety recommendations to the boy and his parents. Which response indicates a need for further teaching? A) "We should avoid aspirin and drugs like ibuprofen." B) "He can resume participation in football in 2 weeks." C) "Swimming would be a great activity." D) "Our son cannot take any antihistamines."
B) "He can resume participation in football in 2 weeks."
A postpartum woman who developed deep vein thrombosis is being discharged on anticoagulant therapy. After teaching the woman about this treatment, the nurse determines that additional teaching is needed when the woman states which of the following? A) "I will use a soft toothbrush to brush my teeth." B) "I can take ibuprofen if I have any pain." C) "I need to avoid drinking any alcohol." D) "I will call my health care provider if my stools are black and tarry."
B) "I can take ibuprofen if I have any pain."
A nurse is preparing to discharge a patient newly prescribed warfarin (Coumadin). While assessing the patient's knowledge of the drug, what would indicate that the patient needs further instruction concerning drug therapy? A) "I love to eat homegrown tomatoes in the summer." B) "I take aspirin for my arthritis." C) "I walk 2 miles a day." D) "I drink a glass of wine about once a week."
B) "I take aspirin for my arthritis."
A patient with chronic pancreatitis had a pancreatojejunostomy 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 appointment. The patient is frustrated that the pain has not decreased. What is the most appropriate initial response by the nurse? A)The majority of patients who have a pancreaticojejunostomy have their normal digestion restored but do not achieve pain relief." B) "Pain relief occurs by 6 months in most patients who undergo this procedure, but some people experience a recurrence of their pain." C) "Your physician will likely want to discuss the removal of your gallbladder to achieve pain relief." D) "You are probably not appropriately taking the medications for your pancreatitis and pain, so we will need to discuss your medication regimen in detail."
B) "Pain relief occurs by 6 months in most patients who undergo this procedure, but some people experience a recurrence of their pain."
A woman is receiving magnesium sulfate as part of her treatment for severe preeclampsia. The nurse is monitoring the woman's serum magnesium levels. Which level would the nurse identify as therapeutic? A) 3.3 mEq/L B) 6.1 mEq/L C) 8.4 mEq/L D) 10.8 mEq/L
B) 6.1 mEq/L
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) Administration of immune globulins B) A regimen of antiviral medications C) Rest and watchful waiting D) Administration of fresh-frozen plasma (FFP)
B) A regimen of antiviral medications
Given the fact that acute pancreatitis can result in severe, life-threatening complications, the nurse should be assessing the client for which of the following complications? A) Cerebral hemorrhage B) Acute tubular necrosis C) Bilateral pneumothorax D) Complete heart block
B) Acute tubular necrosis
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? A) "The symptoms of pancreatitis mimic those of much less serious illnesses." B) "Your body doesn't require pancreatic function until it is under great stress, so it is easy to go unnoticed." C) "Chronic pancreatitis often goes undetected until a large majority of pancreatic function is lost." D) "It's likely that your other organs were compensating for your decreased pancreatic function."
C) "Chronic pancreatitis often goes undetected until a large majority of pancreatic function is lost."
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? A) "Air beds allow the care team to reposition her more easily while she's on bed rest." B) "Air beds are far more comfortable than regular beds and she'll likely have to be on bed rest a long time." C) "The bed automatically moves, so she's less likely to develop pressure sores while she's in bed." D) "The bed automatically moves, so she is likely to have less pain."
C) "The bed automatically moves, so she's less likely to develop pressure sores while she's in bed."
A nurse who provides care at a walk-in clinic assesses a wide range of individuals. The nurse should identify which of the following patients as having the highest risk for chronic pancreatitis? A) A 45-year-old obese woman with a high fat diet B) An 18-year-old man who is a weekend binge drinker C) A 39-year old man with chronic alcoholism D) A 51-year old-woman who smokes one- and one-half packs of cigarettes per day
C) A 39-year old man with chronic alcoholism
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? A) Administer a PRN dose of pancreatic enzymes as ordered. B) Teach the patient about the importance of abstaining from alcohol. C) Arrange for the patient to be transported to the hospital. D) Insert an NG tube, if available, and stay with the patient.
C) Arrange for the patient to be transported to the hospital.
In immune thrombocytopenia purpura (ITP), the client has what type of disorder that primarily destroys which blood component? A) Allergic; fibrinogen B) Alloimmune; factor VIII C) Autoimmune; platelets D) Immunoglobulin; B cells
C) Autoimmune; platelets
A nurse is creating a care plan for a patient with acute pancreatitis. The care plan includes reduced activity. What rationale for this intervention should be cited in the care plan? A) Bed rest reduces the patient's metabolism and reduces the risk of metabolic acidosis. B) Reduced activity protects the physical integrity of pancreatic cells. C) Bed rest lowers the metabolic rate and reduces enzyme production. D) Inactivity reduces caloric need and gastrointestinal motility.
C) Bed rest lowers the metabolic rate and reduces enzyme production.
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? A) Fluid output B) Oral intake C) Blood glucose levels D) BUN and creatinine levels
C) Blood glucose levels
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? A) Educating the patient about expectations and care following surgery B) Educating the patient about the management of blood glucose after discharge C) Educating the patient about post-discharge lifestyle modifications D) Educating the patient about the potential benefits of pancreatic transplantation
C) Educating the patient about post-discharge lifestyle modifications
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? A) Sudden increase in random blood glucose readings B) Increased abdominal girth accompanied by decreased level of consciousness C) Fever, increased heart rate and decreased blood pressure D) Abdominal pain unresponsive to analgesics
C) Fever, increased heart rate and decreased blood pressure
A major factor in the development of hepatic encephalopathy is: A) Hypersplenism B) High sodium level C) Neurotoxin accumulation D) Steroid hormone deficiency
C) Neurotoxin accumulation
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? A) Place hand under the right lower abdominal quadrant and press down lightly with the other hand. B) Place the left hand over the abdomen and behind the left side at the 11th rib. C) Place hand under right lower rib cage and press down lightly with the other hand. D) Hold hand 90 degrees to right side of the abdomen and push down firmly.
C) Place hand under right lower rib cage and press down lightly with the other hand
The nurse is reviewing the laboratory test results of a child diagnosed with disseminated intravascular coagulation (DIC). Which of the following would the nurse interpret as indicative of this disorder? A) Shortened prothrombin time B) Increased fibrinogen level C) Positive fibrin split products D) Increased platelets
C) Positive fibrin split products
A liver failure client asks, "How does the liver process ammonia in healthy individuals?" The health care provider explains that ammonia is toxic to tissues, especially neurons, so this ammonia is removed from the blood by the liver, which: A) Converts it into bilirubin, which is then excreted intestinally B) Processes ammonia into nitrogen and hydrogen ions for excretion C) Processes it into urea, releasing it into the circulation D) Combines it with oxygen to create ammonium oxide
C) Processes it into urea, releasing it into the circulation
A nurse is admitting a patient with immune thrombocytopenic purpura to the unit. In completing the admission assessment, the nurse must be alert for what medications that potentially alter platelet function? Select all that apply. A) Antihypertensives B) Penicillins C) Sulfa-containing medications D) Aspirin-based drugs E) NSAIDs
C) Sulfa-containing medications D) Aspirin-based drugs E) NSAIDs
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? A) Type 1 diabetes B) An impaired immune system C) Undiagnosed chronic pancreatitis D) An amylase deficiency
C) Undiagnosed chronic pancreatitis
An intensive care nurse is aware of the need to identify patients who may be at risk of developing disseminated intravascular coagulation (DIC). Which of the following ICU patients most likely faces the highest risk of DIC? A) A patient with extensive burns B) A patient who has a diagnosis of acute respiratory distress syndrome C) A patient who suffered multiple trauma in a workplace accident D) A patient who is being treated for septic shock
D) A patient who is being treated for septic shock
A patient is being treated for DIC and the nurse has prioritized the nursing diagnosis of Risk for Deficient Fluid Volume Related to Bleeding. How can the nurse best determine if goals of care relating to this diagnosis are being met? A) Assess for edema. B) Assess skin integrity frequently. C) Assess the patient's level of consciousness frequently. D) Closely monitor intake and output.
D) Closely monitor intake and output
The nurse is reviewing the laboratory test results of a pregnant client. Which one of the following findings would alert the nurse to the development of HELLP syndrome? A) Hyperglycemia B) Elevated platelet count C) Leukocytosis D) Elevated liver enzymes
D) Elevated liver enzymes
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? A) Educate the patient about the link between alcohol use and pancreatitis. B) Ensure that the patient knows the importance of attending follow-up appointments. C) Refer the patient to social work or spiritual care. D) Encourage the patient to connect with a community-based support group
D) Encourage the patient to connect with a community-based support group
In the ICU, a postsurgical client has developed sepsis and is being treated with multiple medications. During the mid-morning assessment, which finding leads the nurse to suspect the client may be developing a complication called disseminated intravascular coagulation (DIC)? Select all that apply. A) Headaches associated with light sensitivity B) Oozing from all previous puncture and intravenous sites C) Decreased O2 saturation and diminished breath sounds in lower lobes D) Hemorrhage from the surgical site requiring deep pressure dressings E) Urine from the Foley catheter is bloody
D) Hemorrhage from the surgical site requiring deep pressure dressings
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? A) Position the patient supine to facilitate diaphragm movement. B) Administer corticosteroids by nebulizer as ordered. C) Perform oral suctioning as needed to remove secretions. D) Maintain the patient in a semi-Fowler's position whenever possible.
D) Maintain the patient in a semi-Fowler's position whenever possible.
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? A) Proteinuria and hyperkalemia B) Hemorrhage and hypercalcemia C) Weight loss and hypoglycemia D) Malabsorption and hyperglycemia
D) Malabsorption and hyperglycemia
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? A) Toxins have accumulated and inflamed your pancreas B) Bacteria likely migrated from your intestines and became lodged in your pancreas C) A virus that was likely already present in your body has begun to attack your pancreatic cells D) The enzymes that your pancreas produces have damaged the pancreas itself
D) The enzymes that your pancreas produces have damaged the pancreas itself
A client was started on a protocol for the prevention of deep vein thrombosis shortly after admission and has been receiving 5000 units of heparin twice daily for the last week. An immune response to this treatment may increase the client's chance of developing which health problem? A) Antiphospholipid syndrome B) Disseminated intravascular coagulation (DIC) C) Von Willebrand disease D) Thrombocytopenia
D) Thrombocytopenia
