Nokea
A nurse assesses a client who is recovering from a Whipple procedure. Which assessment finding alerts the nurse to urgently contact the health care provider?
- A. Drainage from a fistula
- B. Pain in the incision site
- C. Nasogastric (NG) tube drainage
- D. Fever of 100.5°F (38.1°C)
Correct Answer: A
Rationale: Drainage from a fistula is a serious complication following a Whipple procedure, indicating potential leakage from surgical anastomoses, which requires urgent medical attention. Pain in the incision site and NG tube drainage are expected postoperative findings, and a mild fever may not be immediately concerning unless accompanied by other symptoms.
You may also like to solve these questions
After teaching a client who is prescribed pancreatic enzyme replacement therapy, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching?
- A. The capsules can be opened and the powder sprinkled on applesauce if needed.
- B. I will take the enzymes with a small sip of water.
- C. The best time to take the enzymes is immediately after I have a meal or a snack.
- D. I will not mix the enzyme powder with food or liquids that contain protein.
Correct Answer: C
Rationale: The enzymes should be taken immediately before eating meals or snacks. If the client cannot swallow the capsule, they can be opened and the powder sprinkled on applesauce or similar foods. The client should wipe their lips carefully after drinking the enzyme preparation because the liquid could damage the skin. Protein items will be dissolved by the enzymes if they are mixed together.
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.
After teaching a client who is recovering from laparoscopic cholecystectomy surgery, the nurse assesses the client's understanding. Which statement by the client indicates a correct understanding of the teaching?
- A. I should avoid fatty foods for a few weeks.
- B. Drinking at least 2 liters of water each day is suggested.
- C. I can resume normal activities immediately.
- D. I should expect severe pain for a few days.
Correct Answer: B
Rationale: Clients recovering from laparoscopic cholecystectomy should maintain adequate hydration to support recovery and prevent complications. Drinking at least 2 liters of water daily is a standard recommendation. Avoiding fatty foods is important but typically advised for longer than a few weeks. Immediate resumption of normal activities is not recommended, and severe pain is not expected.
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.
A nurse cares for a client with end-stage pancreatic cancer. The client asks, 'Why is this happening to me?' How should the nurse respond?
- A. I don't know. I wish I had an answer for you, but I don't.
- B. It helps to keep a positive attitude for your family right now.
- C. Scientists have not determined why cancer develops in certain people.
- D. I think this is a trial so you can become a better person because of it.
Correct Answer: A
Rationale: The client is not asking the nurse to actually explain why the cancer has occurred. The client may be experiencing feelings of confusion, frustration, distress, and grief related to the diagnosis. The nurse should validate that there is no easy or straightforward answer as to why the client has cancer. Other options do not address the client's emotions or current concerns.