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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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A client returns from surgery with a sigmoid colostomy. An ostomy appliance is attached. The priority nursing diagnosis for daily observation and care is:
- A. Diarrhea related to alteration in bowel elimination.
- B. Impaired skin integrity related to seepage.
- C. Impaired nutrition: More than body requirements related to high-fat diet.
- D. Impaired physical mobility related to surgical procedure.
Correct Answer: B
Rationale: The correct answer is B: Impaired skin integrity related to seepage. This is the priority nursing diagnosis because a colostomy appliance can lead to skin breakdown due to seepage of stool, which can cause irritation and skin breakdown. Maintaining skin integrity is crucial to prevent infection and promote healing.
A: Diarrhea is not the priority as it is a common issue after colostomy surgery but can be managed with appropriate interventions.
C: Impaired nutrition is not the priority as it is not specifically related to the immediate care of the colostomy appliance.
D: Impaired physical mobility is not the priority as it is not directly related to the immediate care of the colostomy appliance.
In summary, choice B is the correct answer because maintaining skin integrity is essential for the client's well-being and to prevent complications associated with a colostomy appliance.
A nurse is reviewing the orders of a client admitted to the hospital with a diagnosis of acute pancreatitis. Select the interventions that the nurse would expect to be prescribed for the client.
- A. Small, frequent high-calorie feedings.
- B. Meperidine (Demerol) as prescribed for pain.
- C. Place the client in a side-lying position with the head elevated 45-degrees.
- D. Administer antacids and anticholinergics to suppress gastrointestinal secretions.
Correct Answer: B
Rationale: The correct answer is B: Meperidine (Demerol) as prescribed for pain. In acute pancreatitis, pain management is crucial, and Meperidine is commonly used due to its minimal effect on the sphincter of Oddi.
Incorrect options:
A: Small, frequent high-calorie feedings can exacerbate pancreatitis by stimulating pancreatic enzyme secretion.
C: Placing the client in a side-lying position with the head elevated is not a specific intervention for pancreatitis.
D: Administering antacids and anticholinergics is not a standard treatment for pancreatitis and may not address the underlying cause of the condition.
A client had an abdominal perineal resection with a colostomy 4 days ago and is ready for discharge. Which of the following would be an appropriate expected outcome at this point?
- A. The client maintains a high-fiber diet.
- B. The client discusses concerns about his sexual functioning.
- C. The client maintains bedrest.
- D. The client limits fluid intake to 1000 ml/day.
Correct Answer: B
Rationale: The correct answer is B because discussing concerns about sexual functioning is an appropriate expected outcome at this point. After an abdominal perineal resection with a colostomy, it is important for the client to address any concerns related to sexual functioning as it can impact their quality of life.
A: The client maintaining a high-fiber diet is not the most appropriate expected outcome at this point as it may be too soon after surgery to focus solely on dietary adjustments.
C: The client maintaining bedrest is not appropriate as early mobilization is usually encouraged after surgery to prevent complications.
D: Limiting fluid intake to 1000 ml/day is not recommended as adequate hydration is crucial for recovery post-surgery.
The nurse is caring for a client on the first postoperative day following a surgical repair of an abdominal aortic aneurysm. Which nursing diagnosis is the most important for this client?
- A. Risk for infection
- B. Deficient knowledge
- C. Ineffective peripheral tissue perfusion
- D. Activity intolerance
Correct Answer: C
Rationale: The correct answer is C: Ineffective peripheral tissue perfusion. This is the most important nursing diagnosis because after abdominal aortic aneurysm repair, there is a risk of compromised blood flow to peripheral tissues due to potential complications like embolism or thrombosis. Monitoring tissue perfusion is crucial to prevent complications such as tissue necrosis.
A: Risk for infection is important but not the priority immediately postoperatively.
B: Deficient knowledge may be addressed later once the client is stable.
D: Activity intolerance may be a concern but ensuring tissue perfusion is more critical in the immediate postoperative period.
In summary, monitoring and addressing ineffective peripheral tissue perfusion is essential for preventing serious complications following abdominal aortic aneurysm repair.
The nurse assesses the client's understanding of the relationship between body position and gastroesophageal reflux. Which response would indicate that the client understands measures to avoid problems with reflux while sleeping?
- A. I can elevate the foot of the bed 4 to 6 inches.
- B. I can sleep on my stomach with my head turned to the left.
- C. I can sleep on my back without a pillow under my head.
- D. I can elevate the head of the bed 4 to 6 inches.
Correct Answer: D
Rationale: The correct answer is D: "I can elevate the head of the bed 4 to 6 inches." Elevating the head of the bed helps to prevent gastroesophageal reflux by promoting gravity to keep stomach acid from moving back into the esophagus. This position helps to keep the stomach contents in place and reduces the likelihood of reflux during sleep.
Choice A is incorrect because elevating the foot of the bed would not be effective in preventing reflux; it may even exacerbate the issue. Choice B is incorrect as sleeping on the stomach can increase pressure on the stomach and worsen reflux. Choice C is also incorrect as sleeping on the back without a pillow under the head may not provide the necessary elevation to prevent reflux effectively.