Chapter 59: Care of Patients with Problems of the Biliary System and Pancreas
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 Murphys 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.
After teaching a client who is prescribed pancreatic enzyme replacement therapy, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching? 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. If the client cannot swallow the capsules whole, they can be opened up and the powder sprinkled on applesauce, mashed fruit, or rice cereal. The client should wipe his or her lips carefully after drinking the enzyme preparation because the liquid could damage the skin. Protein items will be dissolved by the enzymes if they are mixed together.
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 nurses 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.
Activities the nurse could suggest to a client interested in preventing gallstone formation include which of the following? a. Drink only bottled water. b. Increase the amount of protein eaten each day. c. Limit the amount of calcium in the diet. d. Maintain a low-fat diet.
ANS: D Health promotion activities that can help limit or prevent gallstone formation include maintaining a low-fat diet, maintaining ideal body weight, and limiting the number of ones pregnancies. Low-carbohydrate diets and physical activity also seem to help.
A client who had pancreatic surgery has been started on medication therapy with pancrelipase (Pancrease). The manifestation that the nurse would report as an indication that the dosage may be insufficient is a. black, tarry stools. b. clay-colored stools. c. constipation. d. steatorrhea.
ANS: D When the client begins to eat, the nurse should watch for the development of diarrhea and steatorrhea (fatty stools), which indicate that insufficient pancreatic enzymes are present.
A nurse cares for a client with acute pancreatitis who is prescribed gentamicin (Garamycin) 3 mg/kg/day in 3 divided doses. The client weighs 264 lb. How many milligrams should the nurse administer for each dose? (Record your answer using a whole number.) ____ mg/dose
ANS: 120 mg/dose264 lb (2.2 lb/kg) = 120 kg.3 mg/kg/day 120 kg = 360 mg/day.360 mg/day 3 divided doses = 120 mg/dose.
A nurse prepares to discharge a client with chronic pancreatitis. Which question should the nurse ask to ensure safety upon discharge? a. Do you have a one- or two-story home? b. Can you check your own pulse rate? c. Do you have any alcohol in your home? d. Can you prepare your own meals?
ANS: A A client recovering from chronic pancreatitis should be limited to one floor until strength and activity increase. The client will need a bathroom on the same floor for frequent defecation. Assessing pulse rate and preparation of meals is not specific to chronic pancreatitis. Although the client should be encouraged to stop drinking alcoholic beverages, asking about alcohol availability is not adequate to assess this clients safety.
A client has returned from an open cholecystectomy. The nurse places the highest priority on which intervention? a. Coughing and deep breathing b. Early ambulation c. Wearing anti-embolic hose d. Use of a nasogastric tube
ANS: A After cholecystectomy, clients find it difficult to take deep breaths and cough independently because of the location of the incision. Preventing pneumonia is a critical outcome of the diagnosis Risk for Injury.
Health promotion activities a nurse could recommend to a client in order to prevent pancreatitis include (Select all that apply) a. avoiding alcohol abuse. b. eating a high-protein diet. c. getting regular exercise. d. losing weight if needed.
ANS: A, D Avoiding alcohol is the best way to promote health and to reduce the chances of developing pancreatitis. Obesity is another major risk factor. Other causes include hyperlipidemia, hypercalcemia, cholecystitis and cholelithiasis, pancreatic tumors or trauma, pancreatic ischemia, and certain drugs.
A nurse assesses a client who has cholecystitis. Which clinical manifestation indicates that the condition is chronic rather than acute?a. Temperature of 100.1 F (37.8 C)b. Positive Murphys sign c. Light-colored stoolsd. Upper abdominal pain after eating
ANS: C Jaundice, clay-colored stools, and dark urine are more commonly seen with chronic cholecystitis. The other symptoms are seen equally with both chronic and acute cholecystitis.
A nurse plans care for a client who has acute pancreatitis and is prescribed nothing by mouth (NPO). With which health care team members should the nurse collaborate to provide appropriate nutrition to this client? (Select all that apply.) a. Registered dietitian b. Nursing assistant c. Clinical pharmacist d. Certified herbalist e. Health care provider
ANS: A, C, E Clients who are prescribed NPO while experiencing an acute pancreatitis episode may need enteral or parenteral nutrition. The nurse should collaborate with the registered dietitian, clinical pharmacist, and health care provider to plan and implement the more appropriate nutritional interventions. The nursing assistant and certified herbalist would not assist with this clinical decision.
A nurse assesses a client who is recovering from a Whipple procedure. Which clinical manifestations alert the nurse to a complication from this procedure? (Select all that apply.) a. Clay-colored stools 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 for which the nurse must assess the client after the Whipple procedure. Clay-colored stools are associated with cholecystitis and are not a complication of a Whipple procedure.
The nurse is providing discharge instructions to a client going home with a T tube after an open cholecystectomy. Goals for teaching have been met when the client says a. For drainage that is thick with mucus or blood, I can irrigate the T tube. b. I will need to milk the tube every 4 hours and record the drainage. c. The tube can be used to administer stone dissolving medications d. This tube will stay in for 1-2 weeks and I should watch for diminishing drainage.
ANS: D The T tube will be removed in 1-2 weeks. Drainage should gradually diminish. Drainage that is thick with blood or mucus needs to be reported to the physician. Milking the tube is not recommended. Stone dissolving medications are given orally.
When a client is admitted to the hospital for treatment of acute cholecystitis, the nurse would anticipate that the immediate medical management will be a.antibiotic therapy. b. provided by a medical nutritionist. c. systemic corticosteroid administration. d. total parenteral nutrition.
ANS: A Clients suspected of having acute cholecystitis may need to be hospitalized, and initial management should include administration of antibiotics effective against organisms found in the bile in approximately 80% of cases.
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 Ringers 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.
A nurse assesses a client with cholelithiasis. Which assessment findings should the nurse identify as contributors to this clients condition? (Select all that apply.) a. Body mass index 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. A diet low in saturated fats and moderate alcohol intake may decrease the risk. Although metabolic syndrome is a precursor to diabetes, it is not a risk factor for cholelithiasis. The client should be informed of the connection.
The nurse is caring for a female client with cholelithiasis. Which assessment findings from the clients 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 would explain that Whipples operation involves a. excavation of a pancreatic abscess and implantation of an external drain. b. removal of the head of the pancreas and portions of the stomach and duodenum. c. surgical removal of a pancreatic pseudocyst and implantation of an external drain. d. surgical removal of the tail of the pancreas and portions of the colon.
ANS: B Surgical management of pancreatic cancer includes Whipples operation, which involves a pancreatoduodenectomy with removal of the distal third of the stomach, the duodenum, common bile duct, gallbladder, and head of the pancreas.
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.
A client being discharged after an episode of acute pancreatitis asks the nurse why items such as coffee/tea, spicy foods, and heavy meals should be avoided. The nurse should reply a. Eating these items may disrupt your sleep and you will need lots of rest. b. So that you wont get reflux disease, which is a common complication. c. Those things stimulate the pancreas too much and may give you another attack. d. Your sense of taste has been altered, and often people dont like these any more.
ANS: C Items such as coffee, spicy foods, and heavy meals stimulate pancreatic secretions and may precipitate another attack of pancreatitis. Other dietary instructions include eating small, frequent meals, and eating high-protein, low-fat foods that are moderate to high in carbohydrates.
A nurse assesses clients at a community health center. Which client is at highest risk for pancreatic cancer? a. A 32-year-old with hypothyroidism b. A 44-year-old with cholelithiasis c. A 50-year-old who has the BRCA2 gene mutation d. A 68-year-old who is of African-American ethnicity
ANS: C Mutations in both the 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 nursing diagnosis that would serve as the primary guide when providing care to a client with cystic fibrosis (CF) is a. Constipation b. Fluid Volume Excess c. Ineffective Airway Clearance d. Swallowing, Impaired
ANS: C Nursing management of the client with CF focuses on two major nursing diagnoses: Ineffective Airway Clearance and Imbalanced Nutrition: Less than Body Requirements.
The nurse is caring for a client with acute pancreatitis. During the physical assessment, the nurse notes a grayish-blue discoloration of the clients flanks. Which is the nurses priority action? a. Prepare the client for emergency surgery. b. Place the client in high Fowlers 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 (Turners 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 recognizes that the individual at highest risk for development of gallstones is a. a 20-year-old black man with sickle cell disease. b. a 35-year-old white woman being treated for breast cancer. c. a 49-year-old white man with a sedentary lifestyle. d. a 60-year-old white woman being treated for obesity.
ANS: D The incidence of gallstones increases with age, as do the risks associated with cholelithiasis. Women account for almost 70% of clients treated for gallstones, although studies have suggested that the death rate is higher in men. Other disorders that are associated with an increased incidence of gallstones are diabetes mellitus, obesity, Crohns diseases, and cirrhosis.
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.
A nurse is providing discharge instructions for a post-cholecystectomy client. The nurse would view the goals for teaching had been effective when the client states he/she would a. call the physician if gas occurs. b. notify the physician of jaundice or itching. c. remain indoors until the dressings are removed. d. report dark-colored stools to the clinic.
ANS: B The nurse should be sure that the client knows which manifestations to report to the physician and how to contact the physician. The client should be instructed to report fever, jaundice, dark-colored urine, pale-colored stools, and pruritus
A nurse assesses clients on the medical-surgical unit. Which client should the nurse identify as at high risk for pancreatic cancer? a. A 26-year-old with a body mass index of 21 b. A 33-year-old who frequently eats sushi c. A 48-year-old who often drinks wine d. A 66-year-old who smokes cigarettes
ANS: D Risk factors for pancreatic cancer include obesity, older age, high intake of red meat, and cigarette smoking. Sushi and wine intake are not risk factors for pancreatic cancer.
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 clients pain? a. Ambulate the client in the hallway. b. Apply a cold compress to the clients 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
A nurse cares for a client who is recovering from laparoscopic cholecystectomy surgery. The client reports pain in the shoulder blades. How should the nurse respond? a. Ambulating in the hallway twice a day will help. b. I will apply a cold compress to the painful area on your back. c. Drinking a warm beverage can relieve this referred pain. d. You should cough and deep breathe every hour.
ANS: A The client who has undergone a laparoscopic cholecystectomy may report free air pain due to retention of carbon dioxide in the abdomen. The nurse assists the client with early ambulation to promote absorption of the carbon dioxide. Cold compresses and drinking a warm beverage would not be helpful. Coughing and deep breathing are important postoperative activities, but they are not related to discomfort from carbon dioxide.
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 who underwent laparoscopic cholecystectomy asks the nurse how soon he/she can return to work. The nurse would respond that the final decision is up to the surgeon, but that clients can usually resume work after a. 24 hours. b. 3 to 4 days. c. 5 to 7 days. d. 2 weeks.
ANS: B Most clients can resume normal activities and return to work in 3 to 4 days after laparoscopic cholecystectomy.
A client is admitted for suspected cholecystitis. On reviewing laboratory results, the nurse notes that the clients 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-Fowlers 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.
A nurse plans care for a client with acute pancreatitis. Which intervention should the nurse include in this clients plan of care to reduce discomfort? a. Administer morphine sulfate intravenously every 4 hours as needed. b. Maintain nothing by mouth (NPO) and administer intravenous fluids. c. Provide small, frequent feedings with no concentrated sweets. d. Place the client in semi-Fowlers position with the head of bed elevated.
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 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 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 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 Blumbergs 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.
A client with a T tube following choledochostomy asks the nurse why the tube is being clamped during mealtimes. The most accurate response by the nurse is a. It causes less pain during mealtime. b. It helps keep the common bile duct patent. c. It helps with digestion of fats in the meal. d. It will help the tube to come out more quickly.
ANS: C After a few days, the T tube will probably be clamped during meals to aid in fat digestion.
A nurse prepares to assess the emotional state of a client with end-stage pancreatic cancer. Which action should the nurse take first? a. Bring the client to a quiet room for privacy. b. Pull up a chair and sit next to the clients bed. c. Determine whether the client feels like talking about his or her feelings. d. Review the health care providers notes about the prognosis for the client.
ANS: C Before conducting an assessment about the clients 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 clients 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 planning the care of a client admitted with severe pancreatitis would anticipate the diet order of a. clear liquids. b. enteral feedings. c. NPO with TPN. d. soft, low fat.
ANS: C Clients with moderate to severe pancreatitis need to be supported nutritionally by total parenteral nutrition (TPN)
A client with acute pancreatitis has a drop in blood pressure from to mm Hg at 2 hours after admission. The client has not voided and has become short of breath. The nurse would anticipate that the abnormal laboratory value consistent with these manifestations is a. hypercalcemia. b. hyperglycemia. c. hypoalbuminemia. d. hypokalemia.
ANS: C Fluid shifts to pleural and abdominal spaces have caused hypovolemia resulting from reduced blood proteins (albumin). The client will show hypoalbuminemia because of reduced blood proteins. This process is called third spacing.
After teaching a client who has a history of cholelithiasis, the nurse assesses the clients understanding. Which menu selection made by the client indicates the client clearly understands the dietary teaching? a. Lasagna, tossed salad with Italian dressing, and low-fat milk b. Grilled cheese sandwich, tomato soup, and coffee with cream c. Cream of potato soup, Caesar salad with chicken, and a diet cola d. Roasted chicken breast, baked potato with chives, and orange juice
ANS: D Clients with cholelithiasis should avoid foods high in fat and cholesterol, such as whole milk, butter, and fried foods. Lasagna, low-fat milk, grilled cheese, cream, and cream of potato soup all have high levels of fat. The meal with the least amount of fat is the chicken breast dinner.
A nurse cares for a client who is prescribed 4 mg of calcium gluconate to infuse over 5 hours. The pharmacy provides 2 premixed infusion bags with 2 mg of calcium gluconate in 100 mL of D5W. At what rate should the nurse administer this medication? (Record your answer using a whole number.) ____ mL/hr
ANS:40 mL/hr
A client returned to the nursing unit after cholecystectomy with common bile duct exploration has bile leaking from around the wound. The most appropriate nursing intervention at this time would be to a. assess the client further, asking about pain. b. reassure the client that this is normal and reinforce the dressing. c. monitor the client for elevations in blood pressure and pulse. d. encourage the client to change position in bed.
ANS: A The risk of bile leakage into the abdominal cavity is more specific for surgeries that involve the gallbladder. With hemorrhage and bile leakage, the client feels severe pain and tenderness in the right upper quadrant; the abdominal girth increases; bile or blood may leak from the wound; blood pressure drops; and tachycardia develops
A nurse assesses a client who is recovering from an open Whipple procedure. Which action should the nurse perform first? a. Assess the clients endotracheal tube with 40% FiO2. b. Insert an indwelling Foley catheter to gravity drainage. c. Place the clients nasogastric tube to low intermittent suction. d. Start lactated Ringers solution through an intravenous catheter.
ANS: A Using the ABCs, airway and oxygenation status should always be assessed first, so checking the endotracheal tube is the first action. Next, the nurse should start the IV line (circulation). After that, the Foley catheter can be inserted and the nasogastric tube can be set.
A nurse cares for a client who presents with tachycardia and prostration related to biliary colic. Which actions should the nurse take? (Select all that apply.) a. Contact the provider immediately. b. Lower the head of the bed. c. Decrease intravenous fluids. d. Ask the client to bear down.e. Administer prescribed opioids.
ANS: A, B Clients who are experiencing biliary colic may present with tachycardia, pallor, diaphoresis, prostration, or other signs of shock. The nurse should stay with the client, lower the clients head, and contact the provider or Rapid Response Team for immediate assistance. Treatment for shock usually includes intravenous fluids; therefore, decreasing fluids would be an incorrect intervention. The clients tachycardia is a result of shock, not pain. Performing the vagal maneuver or administering opioids could knock out the clients compensation mechanism.
A client is being admitted for the eighth exacerbation of chronic pancreatitis in 2 years. The client is frail and emaciated and becomes agitated when the nurse asks about pain medication. Which referral can the nurse make to best meet this clients needs and address potential complications of the condition? The nurse should request a referral to a a. chaplain for spiritual distress related to the chronic nature of the disease. b. chemical dependency counselor to assess and treat substance abuse. c. medical nutritionist to assess and treat the clients malnutrition. d. surgeon to assess whether or not this client can be treated surgically
ANS: B In developed countries, the most common cause of chronic pancreatitis is chronic alcoholism. The major complication is addiction to narcotics. If the client continues to drink, the prognosis is poor. With the frequent exacerbations and agitation when asked about pain control, the nurse can suspect substance abuse in this client and a referral to a chemical dependency counselor would best address that problem.
A nurse cares for a client who is recovering from an open Whipple procedure. Which action should the nurse take? a. Clamp the nasogastric tube. b. Place the client in semi-Fowlers position. c. Assess vital signs once every shift. d. Provide oral rehydration.
ANS: B Postoperative care for a client recovering from an open Whipple procedure should include placing the client in a semi-Fowlers position to reduce tension on the suture line and anastomosis sites, setting the nasogastric tube to low suction to remove free air buildup and pressure, assessing vital signs frequently to assess fluid and electrolyte complications, and providing intravenous fluids.
A nurse cares for a client with pancreatic cancer who is prescribed implanted radioactive iodine seeds. Which actions should the nurse take when caring for this client? (Select all that apply.) a. Dispose of dirty linen in a red biohazard bag. b. Place the client in a private room. c. Wear a lead apron when providing client care. d. Bundle care to minimize exposure to the client. e. Initiate Transmission-Based Precautions.
ANS: B, C, D The client should be placed in a private room and dirty linens kept in the clients room until the radiation source is removed. The nurse should wear a lead apron while providing care, ensuring that the apron always faces the client. The nurse should also bundle care to minimize exposure to the client. Transmission-Based Precautions will not protect the nurse from the implanted radioactive iodine seeds.
The nurse is caring for a client who has just been diagnosed with end-stage pancreatic cancer. The nurse assesses the clients emotional response to the diagnosis. Which is the nurses 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 clients bed. c. Determine whether the client feels like talking about his or her feelings. d. Review the health care providers notes about the prognosis for the client.
ANS: C Before conducting an assessment about the clients 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 clients 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 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 nurses priority action? a. Gently milk the drain tubing. b. Notify the surgeon immediately. c. Document the finding in the clients 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.
A nurse assessing the first 24 hours of drainage from a T tube inserted during surgery for cholelithiasis would record as normal the T-tube output of a. less than 50 ml. b. 100 to 200 ml. c. 300 to 500 ml. d. 500-1000 ml.
ANS: C During the first 24 hours of an insertion of a T-tube, an output of 300 to 500 ml is normal.
The morning after admission, a client being treated for gallstones begins to vomit about every 15 minutes and is complaining of abdominal pain. The most appropriate action by the nurse would be to a. encourage the client to ambulate. b. offer clear fluids. c. prepare to insert a nasogastric tube. d. turn the client to the right side.
ANS: C If the client continues vomiting, the nurse should obtain an order for a nasogastric tube with a suction attachment to relieve the distention and vomiting. Suction also removes the gastric juices that stimulate cholecystokinin, which in turn causes painful contractions of the gallbladder.
To attempt to alleviate the pain of a client with acute pancreatitis, the nurse would place the client in the a. prone position with a pillow under the abdomen. b. semi-Fowler position with a small pillow under the knees. c. side-lying position with a pillow splinting the abdomen. d. supine position with a cold pack to the abdomen.
ANS: C Positioning (side-lying knee-chest position with a pillow pressed against the abdomen, or sitting position with the trunk flexed), back rubs, relaxation techniques, and a quiet environment all help promote comfort and rest.
The nurse recognizes that the client with gallstones who would be the best candidate for treatment with extracorporeal shock wave lithotripsy (ECSL) is a client with a. common bile duct stones. b. liver disease. c. stones that are 6 cm in diameter. d. two gallstones.
ANS: D The client should have symptomatic cholelithiasis with fewer than four stones, each smaller than 3 cm in diameter, and no history of liver or pancreatic disease. Contraindications to ECSL are the presence of common bile duct stones, recent acute cholecystitis, cholangitis, and pancreatitis.
A nurse is teaching a client and spouse about insulin administration. The spouse becomes quite upset, saying Why are we having to use insulin at home? The diagnosis is pancreatitis! How did you make him a diabetic? The best response by the nurse is a. I see you are upset. Let me answer your questions before we talk about insulin. b. Im sorry youre upset. But you both need to understand how to use insulin. c. When so much endocrine tissue is damaged, the client becomes diabetic. d. Would you like the diabetic educator to come talk with you both?
ANS: A The client who loses a great deal of endocrine pancreatic tissue, either through scarring from chronic pancreatitis or from surgical resection, will develop diabetes and will need insulin administration for the rest of the clients life. However, the spouse is too upset to be able to learn, and attending to the psychosocial needs takes precedence before teaching can be done.
A client has been diagnosed with cancer of the gallbladder. Which statement by the client would lead the nurse to feel concern for this clients coping? a. After my chemotherapy is over, I think I will retire and do a lot of traveling. b. Im going to see a lawyer and update my will and advance directives. c. Its hard deciding if I should have chemo or radiation because both have bad results. d. My doctors say there is no agreement on the best treatment.
ANS: A The prognosis for gallbladder cancer is poor; only about 5% of clients with unresectable cancer are alive at the end of the first year after diagnosis. There is no agreement on the best treatment and neither chemotherapy nor radiation therapy offers good outcomes.
After teaching a client who is recovering from laparoscopic cholecystectomy surgery, the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the teaching? a. Drinking at least 2 liters of water each day is suggested. b. I will decrease the amount of fatty foods in my diet. c. Drinking fluids with my meals will increase bloating. 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 procedure. Restriction of sweets is not required.
A client had an endoscopic retrograde papillotomy for stone removal and has returned to the nursing unit. The client is asking for ice chips. What assessment takes priority? The nurse should assess the clients a. bowel sounds. b. gag reflex. c. sedation level. d. vital signs.
ANS: B During this procedure, a local anesthetic is sprayed at the back of the clients throat to facilitate passing the endoscope. The nurse should carefully check for the return of the gag reflex before allowing oral intake. This is the priority assessment as the client is asking for ice chips. The client has probably received sedation for the procedure, making an assessment of sedation level important as well. Vital signs are monitored frequently post-procedure. Bowel sounds are the last priority as the client did not receive general anesthesia.
The nurse is caring for a client who had undergone a Whipple procedure 2 days previously. The nurse notes that the clients 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 clients IV fluid infusion rate. b. Monitor the clients blood sugar level every 4 hours. c. Add colloids to the clients IV solutions. d. Reinsert the clients 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 clients IV regimen will help shift edematous fluid from the interstitial space back into the intravascular space. Increasing the clients 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.
A nurse cares for a client with acute pancreatitis. The client states, I am hungry. How should the nurse reply? a. Is your stomach rumbling or do you have bowel sounds? b. I need to check your gag reflex before you can eat. c. Have you passed any flatus or moved your bowels? d. You will not be able to eat until the pain subsides.
ANS: C Paralytic ileus is a common complication of acute pancreatitis. The client should not eat until this has resolved. Bowel sounds and decreased pain are not reliable indicators of peristalsis. Instead, the nurse should assess for passage of flatus or bowel movement.
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 its out.
ANS: D The provider will discontinue the T-tube. The other statements are accurate.
A nurse cares for a client who has obstructive jaundice. The client asks, Why is my skin so itchy? How should the nurse respond? 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 nurse assesses a client who is recovering from a Whipple procedure. Which assessment finding alerts the nurse to urgently contact the health care provider? a. Drainage from a fistula b. Absent bowel sounds c. Pain at the incision site d. Nasogastric (NG) tube drainage
ANS: A Complications of a Whipple procedure include secretions that drain from a fistula and peritonitis. Absent bowel sounds, pain at the incision site, and NG tube drainage are normal postoperative findings.
The client with obstructive jaundice asks the nurse why his skin is so itchy. Which is the nurses 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 clients 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 (Trousseaus sign) is indicative of hypocalcemia. The clients calcium level is low. The sodium level is high, but that is not related to Trousseaus sign. Creatinine and potassium levels are normal.
In evaluating a client for the presence of gallbladder disease, the nurse would recognize that the clients statement most suggestive of this problem is a. I am having difficulty swallowing. b. I get a sharp, stabbing pain every time I take a deep breath or cough. c. I have a terrible pain in my stomach; it is so bad I can feel it in my shoulder. d. I have a very strong craving for fatty foods like bacon and eggs fried in butter.
ANS: C The most specific and characteristic manifestation of gallstone disease is pain, or biliary colic, which is caused by spasm of the biliary ducts as they try to dislodge stones. This pain usually follows the temporary obstruction of the gallbladder outlet. Characteristically, the pain starts in the upper midline area, and it may radiate around to the back and right shoulder blade, although some clients report that it passes straight through to the back and substernal areas.
A client with a history of cholelithiasis presents at the hospital with nausea and vomiting, abdominal pain, and jaundice. The nurse would assess the client for a. common bile duct obstruction. b. infarct of the hepatic vein. c. perforation of the gallbladder. d. spasm of the biliary tree.
ANS: A Jaundice appears only when common bile duct obstruction is present. Bilirubin, which is normally excreted through the colon, is now in the circulating volume because of the blocked common bile duct and is deposited in the skin and in the urine, causing dark urine, light-colored stools, jaundice, and itching.
In preparing the teaching plan on dietary changes after discharge for a client with chronic pancreatitis, the nurse would know that the statement most indicative of the clients understanding of the information is a. I wont be eating any more French fries or drinking hard liquor. b. A chicken breast and a glass of white wine sound like a good dinner. c. Im anxious to cooperate if it means I can get rid of this pain permanently. d. My diet doesnt sound too bad; lots of people have to watch what they eat.
ANS: A For alcohol-related pancreatitis, total abstinence from alcohol is imperative and sometimes successful in itself for pain relief. A low-fat diet should be prescribed and may reduce painful stimulation of pancreatic enzyme secretion. Clients should understand the benefits of eating small, frequent meals high in protein, low in fat, and moderate to high in carbohydrates.
A nurse collaborates with an unlicensed assistive personnel (UAP) to provide care for a client who is in the healing phase of acute pancreatitis. Which statements focused on nutritional requirements should the nurse include when delegating care for this client? (Select all that apply.) a. Do not allow the client to eat between meals. b. Make sure the client receives a protein shake. c. Do not allow caffeine-containing beverages. d. Make sure the foods are bland with little spice. e. Do not allow high-carbohydrate food items.
ANS: B, C, D During the healing phase of pancreatitis, the client should be provided small, frequent, moderate- to high- carbohydrate, high-protein, low-fat meals. Protein shakes can be provided to supplement the diet. Foods and beverages should not contain caffeine and should be bland.
A client is admitted with acute pancreatitis. The orders are for pancreatic rest. The nurse would implement which of the following? (Select all that apply.) a. Administering pancreatic enzymes with meals b. Bed rest with appropriate positioning c. Immediate insertion of an NG tube d. Withholding foods and liquids
ANS: B, D Pancreatic rest includes keeping the client NPO and, initially, bed rest. NG tube placement is considered only for clients with severe pain or ileus with distention or vomiting. When the client is allowed to eat, pancreatic enzyme replacement may be needed, but is not considered part of pancreatic rest.
The nurse explains that for a client who is a poor surgical risk, one of the nonsurgical alternatives for gallstone disease is a. abdominal ultrasound. b. laser therapy. c. retrograde endoscopy. d. T-tube placement.
ANS: C Retrograde endoscopy for stone removal is an important nonsurgical alternative. To remove a gallstone from the common bile duct, the physician passes an endoscope orally into the duodenum, and then passes a wire snare into the common bile duct through the ampulla of Vater, securing and removing the obstructing stone
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.
A client who had onset of acute pancreatitis 6 days ago has a respiratory rate of 26 with fine crackles throughout lung fields, and seems a little confused and agitated. The nurse would continue to assess this client for manifestations of a. adult respiratory distress syndrome. b. atelectasis and pneumonitis. c. pneumonia. d. tension pneumothorax
ANS: A Manifestations of adult respiratory distress syndrome (ARDS) secondary to acute pancreatitis include respiratory distress, tachypnea, dyspnea, fever, dry cough, fine crackles heard throughout lung fields, possible confusion and agitation, and hypoxemia with arterial oxygen level below 50 mm Hg.
A client with acute pancreatitis has developed a Cullens sign. Which nursing diagnosis takes priority for this client? a. Acute Pain b. Altered Nutrition c. Imbalanced Fluid Volume d. Ineffective Breathing Patterns
ANS: A Severe hemorrhagic pancreatitis may produce two distinctive manifestations: Turners sign (bluish discoloration of the left flank) and Cullens sign (bluish discoloration of the periumbilical area). Cullens sign indicates bleeding into the peritoneum, making the clients priority problem Imbalanced Fluid Volume.
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 nurses best response? a. I dont know. I wish I had an answer for you, but I dont. b. Its 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.
A nurse cares for a client with end-stage pancreatic cancer. The client asks, Why is this happening to me? How should the nurse respond? a. I dont know. I wish I had an answer for you, but I dont. b. Its 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 to actually explain why the cancer has occurred. The client may be expressing his or her feelings of confusion, frustration, distress, and grief related to this diagnosis. Reminding the client to keep a positive attitude for his or her family does not address the clients emotions or current concerns. The nurse should validate that there is no easy or straightforward answer as to why the client has cancer. Telling a client that cancer is a trial is untrue and may diminish the client-nurse relationship.
A nurse cares for a client who is prescribed patient-controlled analgesia (PCA) after a cholecystectomy. The client states, When I wake up I am in pain. Which action should the nurse take? a. Administer intravenous morphine while the client sleeps. b. Encourage the client to use the PCA pump upon awakening. c. Contact the provider and request a different analgesic. d. Ask a family member to initiate the PCA pump for the client.
ANS: B The nurse should encourage the client to use the PCA pump prior to napping and upon awakening. Administering additional intravenous morphine while the client sleeps places the client at risk for respiratory depression. The nurse should also evaluate dosages received compared with dosages requested and contact the provider if the dose or frequency is not adequate. Only the client should push the pain button on a PCA pump.
A nurse teaches a client who is recovering from acute pancreatitis. Which statements should the nurse include in this clients teaching? (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 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.
