Nokea
A nurse assesses a client who has cholecystitis. Which clinical manifestation indicates that the condition is chronic rather than acute?
- A. Temperature of 100°F (37.8°C)
- B. Positive Murphy's sign
- C. Light-colored stools
- D. Upper abdominal pain after eating
Correct Answer: C
Rationale: Hematuria, 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.
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A nurse assesses a client who is recovering from an open Whipple procedure. Which action should the nurse perform first?
- A. Assess the client's endotracheal tube with 40% FiO2.
- B. Insert an indwelling Foley catheter to gravity drainage.
- C. Place the client's nasogastric tube to low intermittent suction.
- D. Start lactated Ringer's solution through an intravenous catheter.
Correct Answer: A
Rationale: 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 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 linens in a biohazard bag.
- B. Place the client in a private room.
- C. Wear a lead apron when providing client care.
- D. Bundle client care to minimize exposure.
- E. Initiate Transmission-Based Precautions.
Correct Answer: B,C,D
Rationale: The client should be placed in a private room, and dirty linens kept in the client's room until the radiation source is removed. The nurse should wear a lead apron while providing care, ensuring the apron always faces the client. Bundling care minimizes exposure to radiation. Transmission-Based Precautions are not necessary for implanted radioactive iodine seeds.
A nurse plans care for a client with acute pancreatitis. Which intervention should the nurse include in this client's 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-Fowler's position with the head of bed elevated.
Correct Answer: B
Rationale: 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 5 hours. A fetal position with legs drawn up to the chest will promote comfort.
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 high-protein intake.
- C. Do not allow caffeine-containing beverages.
- D. Make sure the foods are bland with little spice.
- E. Allow high-carbohydrate food items.
Correct Answer: A,B,C,D
Rationale: 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 nurse cares for a client with acute pancreatitis who is prescribed gentamicin (Garamycin) 3 mg/kg/day in 3 divided doses. The client's weight is 264 lb. How many milligrams should the nurse administer for each dose? (Record your answer using a whole number.)
Correct Answer: 120 mg/dose
Rationale: 264 lb (120 kg) ? 3 mg/kg/day = 360 mg/day. 360 mg/day ÷ 3 divided doses = 120 mg/dose.