Nokea
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.
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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 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.
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 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.
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.