Nokea
A nurse assesses a client with cholelithiasis. Which assessment findings should the nurse identify as risk factors for this condition? (Select all that apply.)
- A. Body mass index of 46
- B. Vegetarian diet
- C. Drinking 8 ounces of red wine nightly
- D. Pregnant with twins
- E. History of metabolic syndrome
Correct Answer: A,D,E
Rationale: Obesity, pregnancy, and diabetes (often associated with metabolic syndrome) are risk factors for the development of cholelithiasis. A vegetarian diet low in saturated fats and moderate alcohol intake may decrease the risk.
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A nurse cares for a client who is prescribed patient-controlled analgesia (PCA) after a cholecystectomy. The client states, 'When I wake up, I am in pain.' Which action should the nurse take?
- A. Administer intravenous morphine while the client sleeps.
- B. Encourage the client to use the PCA pump upon awakening.
- C. Administer intravenous morphine while the client is awake.
- D. Ask a family member to initiate the PCA pump for the client.
Correct Answer: B
Rationale: The nurse should encourage the client to use the PCA pump prior to napping and upon awakening. Administering additional intravenous morphine while the client sleeps places the client at risk for respiratory depression. Only the client should push the pain button on a PCA pump.
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 who has obstructive jaundice. The client asks, 'Why is my skin so itchy?' How should the nurse respond?
- A. Bile salts accumulate in the skin and cause the itching.
- B. Toxes released from an inflamed gallbladder lead to itching.
- C. The nurse assesses the client who is itching.
- D. Itching is caused by a hypersensitivity reaction.
Correct Answer: A
Rationale: In obstructive jaundice, the normal flow of bile into the duodenum is blocked, allowing excess bile salts to accumulate on the skin. This leads to itching, or pruritus. The other statements are not accurate.
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 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.