Med Surg - Chapter 59 - Care of Patients with Problems of the Biliary System and Pancreas

A patient who underwent a traditional cholecystectomy is concerned that the drainage in the Jackson-Pratt drain is now green. What statement by the nurse is most appropriate? 1 "It is normal for the first 24 hours." 2 "The drain may need to be repositioned." 3 "Why don't we have you roll on your other side?" 4 "I'm going to take a small sample and send it to the lab."

1 "It is normal for the first 24 hours." It is normal to have green bile drainage and serosanguinous fluid for the first 24 hours after a Jackson-Pratt drain is placed in a surgery. The drain should not need to be repositioned. The patient does not need to be rolled to the other side. It is not necessary to take a sample to send to the lab.

A patient who has undergone an open cholecystectomy reports mild to moderate nausea. Which nursing action is correct? 1 Administer an antiemetic as prescribed as soon as possible. 2 Give the patient clear liquids and monitor the patient's response. 3 Notify the provider that the patient may have an abdominal obstruction. 4 Withhold antiemetic medications until the patient has increased nausea.

1 Administer an antiemetic as prescribed as soon as possible. Patients who have nausea and vomiting after a cholecystectomy should receive antiemetics as soon as possible to prevent retching that might increase pain related to muscle straining. Giving clear liquids without an antiemetic may increase the nausea and induce vomiting. Mild to moderate nausea does not indicate abdominal obstruction.

A patient suspected of having cholecystitis presents with severe upper epigastric pain radiating to the right shoulder. The patient is vomiting and has abdominal distention. What findings do these symptoms indicate? 1 Biliary colic 2 Liver involvement 3 Chronic cholecystitis 4 Positive Blumberg's sign

1 Biliary colic Biliary colic is consistent with the patient's symptoms. The patient's symptoms do not indicate liver involvement. Chronic cholecystitis would not be an acute presentation as seen with this patient. Blumberg's sign is rebound tenderness, not upper epigastric pain radiating to the right shoulder.

What dietary suggestions are indicated for a patient who is in the healing phase after acute pancreatitis? Select all that apply. 1 Bland foods 2 Low-fat foods 3 Low-protein foods 4 Small, frequent meals 5 Low-carbohydrate foods

1 Bland foods 2 Low-fat foods 4 Small, frequent meals Patients in the healing phase after acute pancreatitis should have bland, low-fat foods and small, frequent meals. Patients should have a high, not low, carbohydrate diet and a high, not low, protein diet.

The nurse is planning discharge teaching for a patient following a cholecystectomy. Which symptoms of post-cholecystectomy syndrome should the patient be taught to report? Select all that apply. 1 Diarrhea 2 Vomiting 3 Dyspepsia 4 Eructation 5 Epigastric pain

1 Diarrhea 2 Vomiting 5 Epigastric pain Diarrhea, vomiting, and epigastric pain are signs of post-cholecystectomy syndrome. Dyspepsia and eructation are not symptoms of post-cholecystectomy syndrome.

When performing an abdominal assessment on a patient diagnosed with pancreatitis, the nurse notes gray-blue discoloration around the periumbilical area, a dull sound on percussion, and normal bowel sounds. What action by the nurse is priority? 1 Document the findings 2 Prepare the patient for the operating room 3 Contact the health care provider immediately 4 Obtain a stat hemoglobin and hematocrit level

1 Document the findings A blue discoloration around the periumbilical area is a normal finding in a patient with acute pancreatitis. A dull sound on percussion may be caused from pancreatic ascites. The findings should be documented. The patient does not need to go to the operating room. The health care provider does not need to be contacted immediately. Checking the hemoglobin and hematocrit level is not indicated.

Which enzyme is involved in enzymatic fat necrosis of the endocrine and exocrine cells of the pancreas? 1 Lipase 2 Trypsin 3 Elastase 4 Kallikrein

1 Lipase The lipase enzyme is involved in enzymatic fat necrosis of both the endocrine and exocrine cells of the pancreas. Trypsin activates elastase, which dissolves the elastic fibers of the blood vessels and ducts. Kallikrein releases vasoactive peptides, bradykinin, and a plasma kinin known as kallidin.

A patient who has cholesterol-based gallstones and good gallbladder function is interested in nonsurgical management options for this condition. Which other factor must be present for this patient to be a candidate for a nonsurgical approach? 1 Normal weight 2 Absence of infection 3 Low serum cholesterol 4 Ability to tolerate iodine

1 Normal weight Patients who undergo extracorporeal shock wave lithotripsy must be of normal weight and have cholesterol-based, smaller gallstones and good gallbladder function. Iodine is not used in this procedure. The presence of infection and serum cholesterol levels are not factors to consider in candidates for this procedure.

Which patients are suitable candidates for extracorporeal shock wave lithotripsy (ESWL) to treat gallstones? Select all that apply. 1 Patient with normal body weight 2 Patient with cancer of the gallbladder 3 Patient with cholesterol-based stones 4 Patient with good gallbladder function 5 Patient with severe biliary obstruction

1 Patient with normal body weight 3 Patient with cholesterol-based stones 4 Patient with good gallbladder function ESWL is used for patients who have small stones and for those who are not good surgical candidates. Patients who are within normal weight range, have cholesterol-based stones, and good gallbladder function are suitable candidates for this procedure. ESWL is not used for patients with severe biliary obstruction or cancer of the gallbladder.

An older patient diagnosed with cholecystitis presents with acute confusion and minimal pain. The family is concerned that the patient is confused and wants to know why the patient did not have other symptoms associated with cholecystitis. What statement by the nurse is most appropriate? 1 "I'll have the health care provider come and talk to you." 2 "Older patients often don't have expected symptoms of cholecystitis." 3 "The patient probably wasn't able to tell you because of the confusion." 4 "Most of the time, confusion is the only thing the patients present with."

2 "Older patients often don't have expected symptoms of cholecystitis." Older patients often do not have typical symptoms of cholecystitis. It is not necessary to get the health care provider; the nurse can provide this information to the patient's family. The patient presented with acute confusion, which is a sign of cholecystitis. Confusion likely developed as a result of cholecystitis. Not all patients with cholecystitis demonstrate confusion.

Which symptom of chronic pancreatitis also occurs with acute pancreatitis? 1 Ascites 2 Abdominal pain 3 Protein malabsorption 4 Loss of exocrine function

2 Abdominal pain Abdominal pain occurs with both types of pancreatitis, although pain intensity does vary between the two. Ascites, loss of exocrine function, and protein malabsorption occur only with chronic pancreatitis.

A patient admitted for cholecystitis presents with the following vital signs: blood pressure 145/92, pulse 108, and temperature of 101.8°F. What action by the nurse is priority? 1 Request a STAT ultrasound 2 Administer PRN ketorolac (IV) 3 Request an order to increase the IV fluids 4 Place the patient supine with the head of bed flat

2 Administer PRN ketorolac (IV) The patient is febrile, tachycardic, and hypertensive, which is expected with inflammation and pain. Administering the PRN ketorolac (a nonsteroidal anti-inflammatory drug) may reduce the fever and the pulse. Although dehydration may be a cause for tachycardia and fever, the patient is also hypertensive, so dehydration is less likely. A STAT ultrasound is not indicated because the cause of the patient's pain and fever is established. The patient with acute abdominal pain will have worsened symptoms when placed supine with the bed flat.

Which factors increase the risk of developing pancreatic cancer? Select all that apply. 1 Aging 2 Cirrhosis 3 Smoking 4 Vitamin deficiency 5 Chronic pancreatitis

2 Cirrhosis 3 Smoking 5 Chronic pancreatitis Pancreatic cancer is an abnormal growth in the pancreas. Cirrhosis, cigarette smoking, and chronic pancreatitis cause chronic irritation of the pancreatic tissue, increasing the risk for pancreatic cancer. Aging and vitamin deficiencies are not risk factors associated with pancreatic cancer.

The nurse is caring for a patient with chronic pancreatitis. What assessment findings are related to this disease process? Select all that apply. 1 Diarrhea 2 Jaundice 3 Polydipsia 4 Polyphagia 5 Weight gain

2 Jaundice 3 Polydipsia 4 Polyphagia Jaundice, polydipsia, and polyphagia are manifestations observed in chronic pancreatitis. Jaundice occurs because of chronic inflammation in the biliary tract; bile cannot drain into the small intestines. Excessive thirst (polydipsia) and an increased appetite (polyphagia) occur because the patient has chronic organ dysfunction and develops diabetes mellitus (of which both symptoms are common). Diarrhea is not a symptom of chronic pancreatitis. Weight loss occurs in chronic pancreatitis.

Which symptoms present in a patient with acute pancreatitis indicate complications? Select all that apply. 1 Vertigo 2 Jaundice 3 Depression 4 Darkened urine 5 Clay-colored stools

2 Jaundice 4 Darkened urine 5 Clay-colored stools Acute pancreatitis occurs because of an inflammation of the pancreas. The enzymes released by the pancreas cause autolysis of the pancreatic tissue. Jaundice, darkened urine, and clay-colored stools indicate complications of acute pancreatitis. Jaundice occurs because of an obstruction in the biliary tract, where bile cannot be absorbed into the gastrointestinal tract. Bile salts accumulate in the skin, causing a yellowish discoloration. An increase in serum bilirubin due to the biliary obstruction causes darkened urine. Stools become clay-colored because of an obstruction in the biliary tract. Vertigo and depression are not symptoms of acute pancreatitis.

The nurse understands that which patient is at highest risk for developing gallstones? 1 Thin female who has recently given birth 2 Obese female on hormone replacement therapy 3 Thin male with a history of coronary artery bypass grafting 4 Obese male with a history of chronic obstructive pulmonary disease

2 Obese female on hormone replacement therapy Both obesity and altered hormone levels increase a woman's risk for developing gallstones. Men are at lower risk than women for developing gallstones. Although pregnancy increases the risk for a woman to develop gallstones, this woman's thin frame lessens that risk.

Which factor is considered a risk factor in the development of cholelithiasis? 1 Anemia 2 Pregnancy 3 Less than age 40 years 4 Low body mass index (BMI)

2 Pregnancy In pregnancy, hormone levels (progesterone and estrogen) are altered, which delays muscular contraction of the gallbladder and decreases the rate of bile emptying, thus increasing the risk for cholelithiasis. Similarly, hormonal changes and hormonal replacement therapy make women over 40 years, not under, more susceptible to the development of cholelithiasis. Obese women, not those with a low BMI, are at a high risk of developing cholelithiasis because of impaired fat metabolism and increased cholesterol. Anemia is not associated with the development of gallstones.

What medications are administered to a patient with acute pancreatitis to decrease gastric acid secretion? Select all that apply. 1 Imipenem 2 Ranitidine 3 Meperidine 4 Omeprazole 5 Ciprofloxacin

2 Ranitidine 4 Omeprazole Ranitidine is a histamine receptor antagonist, and omeprazole is a proton pump inhibitor. Both medications help decrease gastric acid secretion. Imipenem and ciprofloxacin are antibiotics. Meperidine is an opiate analgesic.

A female patient is scheduled for a cholecystectomy by natural orifice transluminal endoscopic surgery. Which area is most commonly used for inserting the endoscope during this procedure? 1 Mouth 2 Vagina 3 Rectum 4 Umbilicus

2 Vagina Surgical removal of the gallbladder in women is most often accomplished via the vagina because it is easily decontaminated with betadine or other antiseptic, and it allows easy access into the peritoneal cavity. The surgeon makes a small internal incision through the cul-de-sac of Douglas, between the rectum and uterine wall, to access the gallbladder. The mouth and rectum do not provide easy access into a woman's peritoneal cavity. The umbilicus is used for removing the gallbladder in laparoscopic cholecystectomy.

The nurse is educating the patient on what to expect after laparoscopic cholecystectomy. Which statement made by the patient reflects a need for further education? 1 "I will probably be able to shower normally the day after my surgery." 2 "Deep-breathing exercises can help me manage my pain after surgery." 3 "I should avoid moving my legs as I recover from surgery to prevent injury." 4 "I can apply ice to the incision to help with pain in the first few days after surgery."

3 "I should avoid moving my legs as I recover from surgery to prevent injury." After laparoscopic cholecystectomy, the patient should regularly do leg exercises to prevent deep vein thrombosis. The patient is therefore incorrect in stating that he or she should avoid moving the legs during recovery. The statements about showering, deep-breathing exercises, and ice for pain relief are correct and do not require further education from the nurse.

What imaging will provide the most reliable diagnosis of acute pancreatitis? 1 Chest x-ray 2 Abdominal ultrasound 3 Contrast-enhanced computed tomography 4 Endoscopic retrograde cholangiopancreatography (ERCP)

3 Contrast-enhanced computed tomography Contrast-enhanced computed tomography provides more reliable images and diagnosis of acute pancreatitis. A chest x-ray will show elevation but is not diagnostic. An abdominal ultrasound is not helpful to view the whole pancreas. An ERCP is better for diagnosing pancreatic stones, not acute pancreatitis.

A patient who has undergone a laparoscopic cholecystectomy reports mild postoperative abdominal bloating and discomfort. Which nursing action is correct? 1 Notify the provider of possible peritonitis 2 Administer an opioid analgesic medication 3 Encourage the patient to ambulate in the hall 4 Withhold oral fluids until these symptoms have passed

3 Encourage the patient to ambulate in the hall Early ambulation can help promote absorption of the carbon dioxide used to insufflate the abdomen. Signs of continued CO 2 retention are abdominal bloating and discomfort. Opioid analgesics are not recommended for mild pain. The patient would have severe discomfort and a rigid abdomen if peritonitis were present. The patient does not require oral fluid restriction.

The nurse is reviewing the lab results of a patient diagnosed with cholecystitis. Elevations in which results would prompt the nurse to suspect abnormal liver function in this patient. Select all that apply. 1 Serum amylase 2 White blood cell count 3 Lactate dehydrogenase 4 Serum alkaline phosphate 5 Aspartate aminotransferase

3 Lactate dehydrogenase 4 Serum alkaline phosphate 5 Aspartate aminotransferase Lactate dehydrogenase, serum alkaline phosphate, and aspartate aminotransferase are all labs that would indicate abnormalities in liver function. Elevated serum amylase would indicate pancreatic involvement. An elevated white blood cell count indicates inflammation.

The patient recently diagnosed with acute pancreatitis complains of severe pain despite intravenous narcotic pain medication. Into which position should the nurse assist the patient in order to help decrease pain? 1 Prone 2 Supine 3 Side lying 4 High Fowler's

3 Side lying The side-lying position may decrease the abdominal pain of pancreatitis. Prone, supine, and high Fowler's positions are not indicated to decrease pain in pancreatitis.

The nurse is teaching a patient with gallbladder disease about diet modification. Which meal does the nurse suggest to the patient? 1 Steak and french fries 2 Sausage and scrambled eggs 3 Turkey sandwich on wheat bread 4 Fried chicken and mashed potatoes

3 Turkey sandwich on wheat bread Turkey is an appropriate low-fat selection for this patient. Steak, french fries, fried chicken, and sausage are too fatty, and eggs are too high in cholesterol for a patient with gallbladder disease.

The nurse is providing teaching about pancreatic enzyme replacement to a patient diagnosed with chronic pancreatitis. What statement by the patient indicates need for further teaching? 1 "I will swallow the tablet without chewing." 2 "I won't mix the enzyme with protein foods." 3 "I will take my pancreatic enzymes after my antacid." 4 "I will take the pancreatic enzyme half an hour before meals."

4 "I will take the pancreatic enzyme half an hour before meals." Pancreatic enzymes should be taken with meals and snacks, not a half hour before meals. The pill should be swallowed without chewing. The enzyme should not be mixed with protein foods. The pancreatic enzyme should be taken after an antacid.

A patient reports fever, yellowing of the skin and eyes, clay-colored stools, and dark urine. The nurse suspects further testing will reveal which condition? 1 Peritonitis 2 Malnutrition 3 Vitamin deficiency 4 Chronic cholecystitis

4 Chronic cholecystitis Fever, yellowing of the skin and eyes, clay-colored stools, and dark urine are symptoms of chronic cholecystitis. These symptoms occur when repeated episodes of cystic duct obstruction cause chronic inflammation. Peritonitis is an infection of the peritoneal cavity in which the patient presents with a hard, distended abdomen. Patients with malnutrition are underweight for their height and have low albumin. Patients with a vitamin deficiency do not display these symptoms; symptoms are always dependent upon the vitamin in which the patient is deficient.

Which enzyme is responsible for the release of vasoactive peptides, bradykinin, and a plasma kinin? 1 Lipase 2 Trypsin 3 Elastase 4 Kallikrein

4 Kallikrein Kallikrein releases vasoactive peptides, bradykinin, and a plasma kinin known as kallidin. These substances cause vasodilation and increased vascular permeability, compounding the hemorrhagic process. Lipase enzyme is involved in enzymatic fat necrosis. Trypsin activates elastase, which dissolves elastic fibers of the blood vessels and ducts.

A patient with acute cholecystitis is admitted to the medical-surgical unit. Which nursing intervention is most appropriately delegated to the unlicensed assistive personnel (UAP)? 1 Checking for bowel sounds and distention 2 Assessing dietary risk factors for cholecystitis 3 Determining precipitating factors for abdominal pain 4 Obtaining the admission weight, height, and vital signs

4 Obtaining the admission weight, height, and vital signs Obtaining height, weight, and vital signs are included in the education for the UAP and usually is included in the job description for these staff members. Assessment, checking bowel sounds, and determining precipitating factors for abdominal pain require broader education and are within the scope of practice of licensed nursing staff.

A patient who has undergone an open cholecystectomy 12 hours prior has a Jackson-Pratt (JP) drain. The nurse empties the drainage and notes bile-stained serosanguineous fluid. Which nursing action is correct? 1 Contact the provider to report a possible surgical infection. 2 Notify the provider that the patient may have a perforation of the bile duct. 3 Raise the drainage system above the site of insertion to minimize blood loss. 4 Record the amount and color of the fluid and continue to monitor the patient.

4 Record the amount and color of the fluid and continue to monitor the patient. JP drainage is generally serosanguineous and is expected to be bile-stained for the first 24 hours after surgery. The color of the fluid does not represent infection, perforation, or excessive blood loss. It is never correct to raise the drainage system above the insertion site because this can cause backup of bile into the surgical site and increase the risk for infection.

A patient is diagnosed with acute pancreatitis. Which test is a sensitive indicator of biliary obstruction in this disorder? 1 Serum amylase 2 Serum bilirubin 3 Alkaline phosphatase 4 Serum alanine aminotransferase

4 Serum alanine aminotransferase Serum alanine aminotransferase is a sensitive indicator of biliary obstruction in acute pancreatitis. A threefold or greater rise in concentration indicates that the diagnosis of acute biliary pancreatitis is valid. Serum bilirubin, alkaline phosphatase, and serum amylase are diagnostic tests prescribed for a patient with acute pancreatitis but do not reflect biliary obstruction.

A nurse is assessing a patient who presents with severe abdominal pain radiating at times to the shoulder. The nurse notes the patient's skin and sclera are yellow in appearance. The patient reports a sedentary lifestyle and experiences rebound tenderness when tested for Blumberg sign. What does the nurse suspect? 1 The patient has chronic cholecystitis because Blumberg sign is present in this form of the disease. 2 The patient has acute cholecystitis because Blumberg sign is present in this form of the disease. 3 The patient has acute cholecystitis because jaundice and icterus are common in this form of the disease. 4 The patient has chronic cholecystitis because jaundice and icterus are common in this form of the disease.

4 The patient has chronic cholecystitis because jaundice and icterus are common in this form of the disease. Based on the provided information, it is most likely that the patient has chronic cholecystitis. Blumberg sign is present in both forms of the disease, so this information cannot help the nurse determine whether the patient has acute or chronic cholecystitis. The yellow discoloration of the skin (jaundice) and sclera (icterus) are most commonly seen in patients with chronic cholecystitis than in patients with the acute form of the disease.