Exam 9- 2

The nurse is planning care for a client who had a laparoscopic Whipple surgery. For which complications will the nurse assess? Select all that apply. A. Bleeding B. Wound infection C. Intestinal obstruction D. Diabetes mellitus E. Abdominal abscess

A, B, C, D, E

Which diagnostic results lead the nurse to suspect that a client may have gallbladder disease? A. Increased white blood cell (WBC) count, visualization of calcified gallstones, edema of the gallbladder wall B. Decreased WBC count, visualization of calcified gallstones, increased alkaline phosphatase C. Increased WBC count, visualization of noncalcified gallstones, edema of the gallbladder wall D. Decreased WBC count, visualization of noncalcified gallstones, increased alkaline phosphatase

A- Increased white blood cell (WBC) count, visualization of calcified gallstones, edema of the gallbladder wall

While reading a physician's note, the nurse understands that the patient grimaced on palpation of the right upper abdomen during inspiration. Which of the following terms describe this impression? A. (+) Ker's sign B. (+) Murphy's sign C. (+) Cullen's sign D. (+) Blumberg's sign

B- positive murphey's sign

A client with chronic cholecystitis reports pruritus, clay-colored stools, and voiding dark, frothy urine. Which priority laboratory finding will the nurse assess? A. Lipase level B. Total bilirubin C. Liver function tests D. White blood cell count

B- total bilirubin

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."

B- we need to call the dietician to get help in planning your diet

After completing a patient assessment, nurse is highly suspicious of acute cholecystitis. Which of the following would be most helpful to include in the recommendation portion of an SBAR to the provider? A. A complete set of vital signs B. Trending of previous lab results C. A contrast enhanced CT scan D. An abdominal ultrasound

D- an abdominal scan

After teaching a client who has a history of cholelithiasis, the nurse assesses the client's understanding. Which menu selection indicates that the client 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

D- roasted chicken breast, baked potato with chives, and orange juice

The nurse is caring for a patient diagnosed with acalculous cholecystitis. Which of the following can be omitted from the teaching plan for this patient? A. Cardiovascular risk factors B. Effects of biliary stasis C. Signs and symptoms of infection D. Treatments for cholelithiasis

D- treatment for cholelithiasis

Which actions will the nurse take to help relieve the severe pain in a client with acute pancreatitis? Select all that apply. A. Maintaining the client on NPO status B. Administering oral NSAIDs around the clock C. Inserting a nasogastric (NG) tube to low suction D. Providing opioids by patient-controlled analgesia E. Administering pancreatic enzyme replacement therapy F. Assisting the client to a side-lying position with knees drawn up to the chest

A- NPO D- opioids F- side lying

The nurse is caring for a postoperative client who reports pain in the shoulder blades following laparoscopic cholecystectomy surgery. Which direction does the nurse give to the nursing assistant to help relieve the client's pain? a. "Ambulate the client in the hallway." b. "Apply a cold compress to the client's back." c. "Encourage the client to take sips of hot tea or broth." d. "Remind the client to cough and deep breathe every

A- ambulate the client in the hallway

Which action will the nurse take first when an 80-year-old client with acute pancreatitis has no breath sounds in the left lower lung lobe? A. Apply oxygen. B. Assess the breath sounds on the right. C. Notify the primary health care provider. D. Document the finding as the only action.

A- apply oxygen

The nurse is preparing a client who has chronic pancreatitis about how to prevent exacerbations of the disease. Which health teaching will the nurse include? (Select all that apply.) a. "Avoid alcohol ingestion." b. "Be sure and balance rest with activity." c. "Avoid caffeinated beverages." d. "Avoid green, leafy vegetables." e. "Eat small meals and high-calorie snacks."

A- avoid alcohol B- be sure to balance rest with activity C- avoid caffeinated beverages E- eat small meals and high calorie snacks

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?"

A- do you live in a one or two story home

Which signs and symptoms will the nurse expect to find on assessment of a client who is admitted with obstructive jaundice? Select all that apply. A. Pruritus B. Hypertension C. Pale, clay-colored stools D. Dark, coffee-colored urine E. Pink discoloration of sclera

A- pruritis C- pale, clay-colored stools D- dark, coffee-colored urine

The preceptor asks the nursing student why Morphine is prescribed for the patient undergoing HIDA scan. What is the student's best response? A. To increase gallbladder visualization B. To control acute abdominal pain C. To improve pulmonary perfusion D. To slow the patient's respiratory rate

A- to increase gallbladder visualization

The nurse is caring for a female client with cholelithiasis. Which assessment findings from the client's history and physical examination may have contributed to development of the condition? (Select all that apply.) a. Body mass index (BMI) of 46 b. Vegetarian diet c. Drinking 4 ounces of red wine nightly d. Pregnant with twins e. History of metabolic syndrome f. Glycosylated hemoglobin level of 15%

A-BMI of 46 D-pregnant with twins F-A1C of 15%

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."

B-AA meetings D-cooking spray F-nicotine patch

A client is experiencing an attack of acute pancreatitis. Which nursing intervention is the highest priority for this client? A. Assist the client to assume a position of comfort. B. Administer opioid analgesic medication. C. Do not administer food or fluids by mouth. D. Measure intake and output every shift.

B- administer opioid analgesic medication

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

B- applying a skin barrier around the drainage tube site

A client is admitted for suspected cholecystitis. On reviewing laboratory results, the nurse notes that the client's amylase is elevated. Which action by the nurse is best? a. Document the finding in the chart. b. Ask the client about drinking habits. c. Notify the health care provider. d. Place the client on clear liquids.

B- ask the client about drinking habits

When caring for a patient diagnosed with pancreatic cancer, the nurse understands that the course of treatment will be guided by which of the following? A. Physician preference B. Biopsy results C. The degree of metastasis D. Analgesia for pain control

B- biopsy results

The nurse is preparing and SBAR report to alert the provider of suspected pancreatitis. Which of the following is a symptom associated with acute pancreatitis? A. Intermittent epigastric pain that improves when lying flat. B. constant gnawing mid-abdomen pain that is worse while lying supine C. Right upper quadrant pain accompanied by severe nausea D. Retro peritoneal pain in the lower back and flanks

B- constant gnawing mid-abdominal pain that is worse when lying supine

After teaching a client who is recovering from laparoscopic cholecystectomy surgery, the nurse assesses the client's 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."

B- i will decrease the amount of fatty foods in my diet

The nurse is caring for a client with acute pancreatitis. Which nursing intervention best reduces discomfort for the client? a. Administering morphine sulfate IV every 4 to 6 hours as needed b. Maintaining NPO status for the client with IV fluids c. Providing small, frequent feedings, with no concentrated sweets d. Placing the client in semi-Fowler's position at elevation of 30 degrees

B- maintaning NPO status for the client with IV fluids

Which fluid and electrolyte balance assessment action will the nurse perform most often for a client with pancreatic cancer after surgery with a traditional Whipple procedure? A. Using a reflex hammer to check deep tendon reflexes B. Pinching up skin over the sternum and checking for tenting C. Applying a blood pressure cuff and assessing for a Trousseau sign D. Asking the client whether he or she has noticed tingling or numbness around the mouth

B- pinching up skin over the sternum and checking for tenting

A young adult client admitted with a diagnosis of cholecystitis from cholelithiasis has severe abdominal pain, nausea, and vomiting. Based on these assessment findings, which client problem is the highest priority for nursing intervention at this time? A. Anxiety B. Risk for dehydration C. Acute pain D. Malnutrition

C- acute pain

Which is the most effective action for the nurse to take to assess adequate bowel function in a client with acute pancreatitis who is at risk for the development of paralytic (adynamic) ileus? A. Observing contents of the nasogastric drainage B. Listening for bowel sounds in all four abdominal quadrants C. Asking the client if he or she has passed flatus or had a stool D. Interpreting the report of a CT scan of the abdomen with contrast medium

C- asking the client if he or she has passed flatus or had a stool

The nurse is caring for a client who has just undergone traditional cholecystectomy surgery and has a Jackson-Pratt (JP) drain in place. The nurse notes serosanguineous drainage present in the drain. Which is the nurse's priority action? a. Gently milk the drain tubing. b. Notify the surgeon immediately. c. Document the finding in the client's chart. d. Irrigate the drain with sterile normal saline.

C- document the findings in the client's chart

The nurse documents the vital signs of a client diagnosed with acute pancreatitis: Apical pulse = 116 beats/min Respirations = 28 breaths/min Blood pressure = 92/50 What complication of acute pancreatitis would the nurse suspect that the client might have? a. Electrolyte imbalance b. Pleural effusion c. Internal bleeding d. Pancreatic pseudocyst

C- internal bleeding high HR to compensate for hypovolemia RR increase to increase oxygen in the blood

The nurse is caring for a client with cholecystitis. The client is a poor historian and is unable to tell the nurse when the symptoms started. Which assessment finding indicates to the nurse that the condition is chronic rather than acute? a. Temperature of 100.1° F (37.8° C) b. Positive Murphy's sign c. Light-colored stools d. Upper abdominal pain after eating

C- light colored stools