Nurse questions exam 4
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.
What is pruritus related to in the patient diagnosed with hepatitis? a. Decreased fat intake b. Poor appetite and therefore poor protein intake c. Accumulation of bile salts under the skin d. Altered urinary output of bile
ANS: C Bile salts accumulate under the skin, causing irritation
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 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.
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 Blumberg's 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.
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).
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, Crohn's diseases, and cirrhosis.
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 it's out."
ANS: D The provider will discontinue the T-tube. The other statements are accurate.
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 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.
The client with obstructive jaundice asks the nurse why his skin is so itchy. Which is the nurse's 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 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 client's safety.
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
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. DIF: Application/Applying REF: pp. 1107
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%
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.
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 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.
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.
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.
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.
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
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.
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.
What should a nurse often find in the medical history of a patient diagnosed with pancreatic disease? a. Liver disorders b. Drug abuse c. Alcohol abuse d. Excessive sugar intake
ANS: C Pancreatic disease is often related to alcohol abuse.
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 nurse's 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.
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.
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 patient in acute pain is admitted with pancreatitis. A nurse reviews a laboratory report showing an elevation that is diagnostic for acute pancreatitis. Which laboratory report did the nurse most likely review? a. Serum bilirubin b. Serum calcium c. Serum lipids d. Serum amylase
ANS: D Serum amylase is the most significant of the diagnostic findings.
What action should a nurse implement to prevent complications in a patient with hepatitis who has been prescribed bedrest? a. Raise the knee gatch to prevent the patient from sliding down in bed. b. Provide undisturbed periods of 6 hours to encourage rest. c. Restrict fluids. d. Encourage turning, coughing, and deep breathing every 2 hours.
ANS: D The nurse must encourage measures that will prevent pneumonia and improve impaired skin integrity because of the increased risk factors associated with bedrest.
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 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 goal of medical treatment for patients with cirrhosis is to prevent complications and limit cell damage. A major approach is to promote rest. What rationale supports this approach? a. Allows time for a transplant b. Allows the liver to regenerate c. Prevents red cell destruction d. Decreases the risk of trauma
ANS: B With rest, the liver will regenerate healthy tissue and return to normal functioning. Rest must include other measures to promote healing, such as dietary measures and no alcohol.
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 is hospitalized with acute pancreatitis. The nursing assistant reports to the nurse that when a blood pressure cuff was applied, the client's 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 (Trousseau's sign) is indicative of hypocalcemia. The client's calcium level is low. The sodium level is high, but that is not related to Trousseau's sign. Creatinine and potassium levels are normal.
In evaluating a client for the presence of gallbladder disease, the nurse would recognize that the client's 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."
: 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.
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 client's understanding of the information is a. "I won't 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. "I'm anxious to cooperate if it means I can get rid of this pain permanently." d. "My diet doesn't 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 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.
. 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.
What is the meaning of a dropping bilirubin level in a patient diagnosed with hepatitis? a. Red blood cell destruction is decreasing. b. Liver function is improving. c. Kidneys are compensating for liver dysfunction. d. Kupffer cell damage is continuing.
ANS: B As liver function improves, the bilirubin level will decrease because of the liver's ability to conjugate and excrete the bilirubin. The flow of bile out of the liver increases.
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.
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.
The nurse is caring for a client with acute pancreatitis. During the physical assessment, the nurse notes a grayish-blue discoloration of the client's flanks. Which is the nurse's priority action? a. Prepare the client for emergency surgery. b. Place the client in high Fowler's 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 (Turner's 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.
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 one's pregnancies. Low-carbohydrate diets and physical activity also seem to help.
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 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 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. "I'm sorry you're 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 client's 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.
What is necessary to restrict when the ammonia level of a patient diagnosed with cirrhosis continues to rise? a. Protein b. Carbohydrates c. Fats d. Water-soluble vitamins
ANS: A Ammonia is the waste product of protein breakdown. Decreasing protein intake will decrease the end product.
Which observation by a nurse would indicate blocked flow of bile from the liver to the intestine? a. Clay-colored stools b. Jaundice c. High blood pressure d. Tachycardia
ANS: A Bile is unable to get to feces to give it the normal brown color.
What actions should a nurse implement to correctly assess the progress of ascites on a daily basis? a. Daily weights and abdominal girth measurements b. Intake-output and electrolyte levels c. Blood pressure and pulse d. Daily temperatures and oxygen levels
ANS: A Daily weights and abdominal girth measurements will accurately measure the fluid accumulating in the peritoneal cavity.
What is the highest nursing priority outcome when planning the care for the patient with pancreatitis? a. Patient claims satisfaction with pain control. b. Patient states an understanding of medications needed on discharge. c. Patient's activity level tolerance shows an increase. d. Patient can maintain a normal bowel pattern.
ANS: A Pain control is the most important priority
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 client's 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 client's 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 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
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 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.
. What should a nurse include in the discharge teaching for a patient after a laparoscopic procedure for cholelithiasis? a. Take water-soluble vitamins. b. Follow a low-fat diet. c. Expect light-colored stools for several days. d. Keep dressing over the T-tube dry.
ANS: B After the laparoscopic procedure, the patient is to follow a low-fat diet and take fat-soluble vitamins. Placement of the T-tube is not done with the laparoscopic procedure.
A high ammonia level contributes to hepatic encephalopathy. Which nursing implementation needs to be added to the nursing care plan as this level continues to increase? a. Mouth care b. Increased frequency of neurologic checks c. Oxygen saturation monitoring d. Intake and output
ANS: B As the ammonia level rises, the patient becomes at greater risk for confusion and hepatic coma related to encephalopathy.
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."