Nokea
The nurse is performing an assessment on a client with acute pancreatitis who was admitted to the hospital. Which of the following assessment questions most specifically would elicit information regarding the pain that is associated with acute pancreatitis?
- A. Does the pain in your abdomen radiate to your groin.
- B. Does the pain in your stomach radiate to the back?
- C. Does the pain in your stomach radiate to your lower middle abdomen?
- D. Does the pain in your lower abdomen radiate to the hip?
Correct Answer: B
Rationale: The correct answer is B: "Does the pain in your stomach radiate to the back?" This question is specific to acute pancreatitis as the pain typically radiates from the epigastric area to the back. Pancreatitis pain often presents as severe, constant, and radiating to the back due to the inflammation of the pancreas affecting surrounding structures.
Choice A is incorrect as the pain in acute pancreatitis typically radiates to the back, not the groin. Choice C is incorrect as it specifies a different area in the abdomen, not the typical location for pancreatitis pain. Choice D is incorrect as pancreatitis pain does not typically radiate to the hip.
In summary, understanding the characteristic radiation of pain in acute pancreatitis is key to assessing and differentiating it from other abdominal conditions.
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A nurse has been caring for a client with a Sengstaken-Blakemore tube. The physician arrives on the nursing unit and deflates the esophageal balloon. The nurse should monitor the client most closely for which of the following?
- A. Swelling of the abdomen
- B. Bloody diarrhea
- C. Vomiting blood
- D. An elevated temperature and arise in blood pressure
Correct Answer: C
Rationale: The correct answer is C: Vomiting blood. When the esophageal balloon of the Sengstaken-Blakemore tube is deflated, the risk of esophageal variceal bleeding increases. Vomiting blood indicates active bleeding and requires immediate intervention. Swelling of the abdomen (A) is not directly related to deflating the balloon. Bloody diarrhea (B) is not a common complication of deflating the balloon. An elevated temperature and a rise in blood pressure (D) are not typical signs of complications related to the deflation of the esophageal balloon.
A client is scheduled for an abdominal perineal resection with permanent colostomy. Which of the following measures would most likely be included in the plan for the client's preoperative preparation?
- A. Keep the client NPO for 2 days before surgery.
- B. Administer kanamycin (Kantrex) the night before surgery.
- C. Inform the client that chest tubes will be in place after surgery.
- D. Advise the client to limit activity.
Correct Answer: B
Rationale: The correct answer is B: Administer kanamycin (Kantrex) the night before surgery. This antibiotic is typically given preoperatively to reduce the risk of infection during the surgical procedure. It helps to eliminate or reduce the number of bacteria in the gastrointestinal tract, which could potentially contaminate the surgical site during the abdominal perineal resection with permanent colostomy.
A: Keeping the client NPO for 2 days before surgery is not necessary for this procedure and could lead to unnecessary dehydration and discomfort.
C: Informing the client that chest tubes will be in place after surgery is not directly related to preoperative preparation for this specific surgery.
D: Advising the client to limit activity is important for postoperative recovery, but it is not a preoperative measure specific to this surgery.
A home care nurse is visiting a client with a diagnosis of pernicious anemia that developed as a result of gastric surgery. The nurse instructs the client that because the stomach lining produces a decreased amount of intrinsic factor in this disorder, the client will need
- A. Vitamin B12 injections.
- B. Vitamin B6 injections.
- C. An antibiotic.
- D. An antacid.
Correct Answer: A
Rationale: The correct answer is A: Vitamin B12 injections. Pernicious anemia results from a lack of intrinsic factor, which is necessary for the absorption of vitamin B12 in the intestines. Therefore, the client with this disorder will need vitamin B12 injections to bypass the need for intrinsic factor.
Choice B (Vitamin B6 injections) is incorrect because pernicious anemia specifically involves a deficiency in vitamin B12, not B6. Choice C (An antibiotic) is incorrect as antibiotics are not indicated for pernicious anemia. Choice D (An antacid) is also incorrect as it does not address the underlying issue of vitamin B12 deficiency caused by the lack of intrinsic factor.
The nurse aspirates 40 mL of undigested formula from the client's nasogastric tube. Before administering an intermittent tube feeding, the nurse understands that the 40 mL of gastric aspirate should be
- A. Discarded properly and recorded as output on the client's intake and output record.
- B. Poured into the nasogastric tube through a syringe with the plunger removed.
- C. Mixed with the formula and poured into the nasogastric tube through a syringe with the plunger removed.
- D. Diluted with water and injected into the nasogastric tube by putting pressure on the plunger.
Correct Answer: B
Rationale: The correct answer is B because pouring the 40 mL of gastric aspirate back into the nasogastric tube through a syringe with the plunger removed ensures the undigested formula is returned to the stomach for digestion. This method maintains the balance of electrolytes and nutrients and prevents potential complications.
Choice A is incorrect because discarding the aspirate without returning it to the stomach can lead to electrolyte imbalances and nutritional deficiencies.
Choice C is incorrect because mixing the aspirate with formula before administering it can cause inaccurate dosing and potential nutrient interactions.
Choice D is incorrect because diluting the aspirate with water and forcibly injecting it back into the stomach can cause discomfort and potential complications for the client.
The nurse is caring for a client on the first postoperative day following a surgical repair of an abdominal aortic aneurysm. Which nursing diagnosis is the most important for this client?
- A. Risk for infection
- B. Deficient knowledge
- C. Ineffective peripheral tissue perfusion
- D. Activity intolerance
Correct Answer: C
Rationale: The correct answer is C: Ineffective peripheral tissue perfusion. This is the most important nursing diagnosis because after abdominal aortic aneurysm repair, there is a risk of compromised blood flow to peripheral tissues due to potential complications like embolism or thrombosis. Monitoring tissue perfusion is crucial to prevent complications such as tissue necrosis.
A: Risk for infection is important but not the priority immediately postoperatively.
B: Deficient knowledge may be addressed later once the client is stable.
D: Activity intolerance may be a concern but ensuring tissue perfusion is more critical in the immediate postoperative period.
In summary, monitoring and addressing ineffective peripheral tissue perfusion is essential for preventing serious complications following abdominal aortic aneurysm repair.