Nokea
A nurse is assigned to a 40-year-old client who has a diagnosis of chronic pancreatitis. The nurse reviews the laboratory result, anticipating a laboratory report that indicates a serum amylase level of
- A. 45 units/L
- B. 100 units/L
- C. 300 units/L
- D. 500 units/L
Correct Answer: C
Rationale: The correct answer is C (300 units/L) because in chronic pancreatitis, there is ongoing inflammation and damage to the pancreas, leading to elevated serum amylase levels. A level of 300 units/L is indicative of pancreatitis. Choices A and B are too low for chronic pancreatitis, and choice D is too high and would typically be seen in acute pancreatitis.
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The nurse is preparing a discharge teaching plan for the client who had an umbilical hernia repair. Which of the following would the nurse include in the plan?
- A. Restricting pain medication
- B. Maintaining bedrest
- C. Avoiding coughing
- D. Irrigating the drain
Correct Answer: C
Rationale: The correct answer is C: Avoiding coughing. After umbilical hernia repair, coughing can increase intra-abdominal pressure and strain the surgical site, leading to potential complications like hernia recurrence or wound dehiscence. It is crucial to advise the client to avoid coughing to promote proper healing.
A: Restricting pain medication is not necessary as pain management is essential for the client's comfort and recovery.
B: Maintaining bedrest is not typically required after umbilical hernia repair, as early ambulation is often encouraged to prevent complications like blood clots.
D: Irrigating the drain is not typically part of the discharge teaching plan for umbilical hernia repair, as drains are usually removed before discharge.
The nurse is performing an assessment on a client with acute pancreatitis who was admitted to the hospital. Which of the following assessment questions most specifically would elicit information regarding the pain that is associated with acute pancreatitis?
- A. Does the pain in your abdomen radiate to your groin.
- B. Does the pain in your stomach radiate to the back?
- C. Does the pain in your stomach radiate to your lower middle abdomen?
- D. Does the pain in your lower abdomen radiate to the hip?
Correct Answer: B
Rationale: The correct answer is B: "Does the pain in your stomach radiate to the back?" This question is specific to acute pancreatitis as the pain typically radiates from the epigastric area to the back. Pancreatitis pain often presents as severe, constant, and radiating to the back due to the inflammation of the pancreas affecting surrounding structures.
Choice A is incorrect as the pain in acute pancreatitis typically radiates to the back, not the groin. Choice C is incorrect as it specifies a different area in the abdomen, not the typical location for pancreatitis pain. Choice D is incorrect as pancreatitis pain does not typically radiate to the hip.
In summary, understanding the characteristic radiation of pain in acute pancreatitis is key to assessing and differentiating it from other abdominal conditions.
A client is suspected of having hepatitis. Which diagnostic test results will assist in confirming this diagnosis?
- A. Decreased erythrocyte sedimentation rate
- B. Elevated serum bilirubin
- C. Elevated hemoglobin
- D. Elevated blood urea nitrogen
Correct Answer: B
Rationale: The correct answer is B: Elevated serum bilirubin. Hepatitis is characterized by liver inflammation, which can lead to impaired bilirubin metabolism and increased levels in the blood. Elevated serum bilirubin is a common finding in hepatitis. Decreased erythrocyte sedimentation rate (Choice A) is not specific to hepatitis. Elevated hemoglobin (Choice C) and elevated blood urea nitrogen (Choice D) are not typically associated with hepatitis and are more indicative of other conditions. In summary, elevated serum bilirubin is a key diagnostic marker for confirming a diagnosis of hepatitis.
The home care nurse is visiting a client with a diagnosis of pernicious anemia that developed as a result of gastric surgery. The nurse instructs the client that because the stomach lining produces a decreased amount of intrinsic factor in this disorder, the client will need
- A. Vitamin B12 injections
- B. Vitamin B6 injections
- C. An antibiotic
- D. An antacid
Correct Answer: A
Rationale: The correct answer is A: Vitamin B12 injections. Pernicious anemia results from a lack of intrinsic factor, which is needed for Vitamin B12 absorption. Since the stomach lining produces less intrinsic factor after gastric surgery, the client cannot absorb B12 orally. Therefore, B12 injections are necessary to bypass the need for intrinsic factor. Vitamin B6 injections (B) are not indicated for pernicious anemia. Antibiotics (C) and antacids (D) are not relevant to the treatment of pernicious anemia.
A nurse is preparing to remove a nasogastric tube from a client. The nurse would instruct the client to do which of the following just before the nurse removes the tube?
- A. To perform Valsalva's maneuver
- B. To take hold and hold a deep breath
- C. To exhale
- D. To inhale and exhale quickly
Correct Answer: B
Rationale: The correct answer is B: To take hold and hold a deep breath. This is because holding a deep breath helps prevent the aspiration of gastric contents when removing the nasogastric tube. By taking a deep breath and holding it, the client creates positive pressure in the lungs, which can help prevent the contents from entering the airway.
Rationale for other choices:
A: Performing Valsalva's maneuver (straining while holding breath) can increase intra-abdominal pressure and potentially push gastric contents upward, increasing the risk of aspiration.
C: Exhaling does not provide the same protection against aspiration as holding a deep breath.
D: Inhaling and exhaling quickly does not create the same protective mechanism as holding a deep breath.