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A nurse assesses a client who is recovering from a Whipple procedure. Which clinical manifestations alert the nurse to a complication from this procedure? (Select all that apply.)
- A. Clay-colored stools
- B. Substernal chest pain
- C. Shortness of breath
- D. Lack of bowel sounds and flatus
- E. Urine output of 20 mL/6 hr
Correct Answer: B,C,D,E
Rationale: Myocardial infarction (chest pain), pulmonary embolism (shortness of breath), adynamic ileus (lack of bowel sounds or flatus), and renal failure (urine output of 20 mL/6 hr) are complications of a Whipple procedure. Clay-colored stools are not a typical complication of this procedure.
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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.
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 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 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.
A nurse cares for a client who presents with tachycardia and prostration related to biliary colic. Which actions should the nurse take? (Select all that apply.)
- A. Contact the provider immediately.
- B. Lower the head of the client.
- C. Decrease intravenous fluids.
- D. Ask the client to bear down.
- E. Administer prescribed opioids.ã??ã??ã?ª
Correct Answer: A,B
Rationale: Clients who are experiencing biliary colic may present with tachycardia, pallor, diaphoresis, prostration, or other signs of shock. The nurse should stay with the client, lower the client's head, and contact the provider or Rapid Response Team for immediate assistance. Decreasing fluids or administering opioids could worsen the client's condition.