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A nurse cares for a client with acute pancreatitis. The client states, 'I am hungry.' How should the nurse reply?
- A. Are your bowels rumbling, or do you have bowel sounds?
- B. I need to check your gag reflex before you can eat.
- C. You will not be able to eat until the pain subsides.
- D. You can have a small snack to tide you over.
Correct Answer: C
Rationale: Paralytic ileus is a common complication of acute pancreatitis. The client should not eat until this has resolved. Bowel sounds and decreased pain are not reliable indicators of peristalsis. Instead, the nurse should assess for passage of flatus or bowel movement.
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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 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 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.
A nurse cares for a client who is prescribed 4 mg of calcium gluconate to infuse over 5 hours. The pharmacy provides 2 premixed infusion bags with 2 mg of calcium gluconate in 100 mL of D5W. At what rate should the nurse administer this medication? (Record your answer using a whole number.)
Correct Answer: 40 mL/hr
Rationale: Two bags of 2 mg calcium gluconate in 100 mL D5W each provide a total of 4 mg in 200 mL. To infuse over 5 hours: 200 mL ÷ 5 hr = 40 mL/hr.