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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.
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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.
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.
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 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.