Nokea
A client has an amylase level of 450 units/L and lipase level of 659 units/L. The client has mid-epigastric pain with nausea. What assessment helps the nurse to determine severity of the client's condition?
- A. Ranson's criteria.
- B. Vital signs.
- C. Urine output.
- D. Glasgow Coma Scale.
Correct Answer: A
Rationale: Ranson's criteria (A) assess pancreatitis severity using clinical and lab parameters like age, glucose, and white blood cell count. Vital signs (B) and urine output (C) are general but less specific. Glasgow Coma Scale (D) is for neurological assessment, not pancreatitis severity.
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A client had a total abdominal hysterectomy and bilateral oophorectomy for ovarian carcinoma yesterday. She received 2 mg of morphine via PCA 10 minutes ago. The nurse was assisting her from the bed to a chair when the client felt dizzy and fell into the chair. The nurse should:
- A. Discontinue the PCA pump.
- B. Administer oxygen.
- C. Take the client's blood pressure.
- D. Assist the client back to bed.
Correct Answer: C
Rationale: Dizziness after morphine suggests possible hypotension. Taking the blood pressure identifies the cause and guides further action, such as fluid administration or repositioning.
Which of the following findings is the best indication that fluid replacement for the client in hypovolemic shock is adequate?
- A. Urine output greater than 30 mL/hour.
- B. Systolic blood pressure greater than 110 mm Hg.
- C. Diastolic blood pressure greater than 90 mm Hg.
- D. Respiratory rate of 20 breaths/minute.
Correct Answer: A
Rationale: Adequate fluid replacement in hypovolemic shock is best indicated by a urine output greater than 30 mL/hour, reflecting restored renal perfusion. Blood pressure and respiratory rate improvements are supportive but less specific.
One month following a subtotal gastrectomy for cancer, the nurse is evaluating the nursing care goal related to nutrition. Which of the following indicates that the client has attained the goal? The client has:
- A. Regained weight loss.
- B. Resumed normal dietary intake of three meals a day.
- C. Controlled nausea and vomiting through regular use of antiemetics.
- D. Achieved optimal nutritional status through oral or parenteral feedings.
Correct Answer: D
Rationale: Achieving optimal nutritional status, whether through oral or parenteral feedings, is the primary goal one month post-gastrectomy, as it indicates the client is meeting nutritional needs.
After a cholecystectomy, the client is to follow a low-fat diet. Which of the following foods would be most appropriate to include in a low-fat diet?
- A. Cheese omelet.
- B. Peanut butter.
- C. Ham salad sandwich.
- D. Roast beef.
Correct Answer: D
Rationale: A low-fat diet minimizes gallbladder workload. Roast beef (D) is leaner compared to a cheese omelet (A), peanut butter (B), or ham salad sandwich (C), which are high in fat. Thus, roast beef is the most appropriate choice.
When comparing the hematocrit levels of a postoperative client, the nurse notes that the hematocrit decreased from 36% to 34% on the third day even though the RBC count and hemoglobin value remained within 10 mg/dL and 11.9 g/dL, respectively. The nurse should:
- A. Check the dressing and drains for frank bleeding.
- B. Call the physician.
- C. Continue to monitor vital signs.
- D. Start oxygen at 2 L/minute per nasal cannula.
Correct Answer: C
Rationale: A slight decrease in hematocrit (36% to 34%) on postoperative day 3, with stable RBC count and hemoglobin, is likely due to hemodilution from fluid administration rather than active bleeding. The nurse should continue to monitor vital signs and hematologic parameters. Checking for bleeding is unnecessary without signs of hemorrhage, calling the physician is premature, and oxygen is not indicated.