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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.
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A nurse orientee is preparing to insert a nasogastric tube, and a nurse educator is observing the procedure. Which of the following supplies if obtained by the nurse orientee would indicate a need for further education regarding this procedure?
- A. Half-inch or one-inch tape
- B. Oil-soluble lubricant
- C. A glass of tap water with a straw
- D. A 50-mL catheter tip syringe
Correct Answer: B
Rationale: The correct answer is B: Oil-soluble lubricant. The rationale is that oil-based lubricants should not be used for nasogastric tube insertion due to the risk of aspiration pneumonia. The other options are appropriate for the procedure: A) Tape is used to secure the tube, C) Water with a straw is used to check tube placement, and D) A syringe is used for verification of tube placement and administration of medications. Therefore, selecting B indicates a lack of understanding of proper supplies for nasogastric tube insertion.
The client with chronic pancreatitis needs information on dietary modification to manage the health problem. The nurse teaches the client to limit which of the following items in the diet?
- A. Carbohydrate
- B. Protein
- C. Fat
- D. Water-soluble vitamins
Correct Answer: C
Rationale: The correct answer is C: Fat. In chronic pancreatitis, the pancreas struggles to produce digestive enzymes, leading to poor fat digestion. Limiting fat intake can help reduce symptoms like abdominal pain and diarrhea. Carbohydrates and proteins are essential for energy and tissue repair, so limiting them is not ideal. Water-soluble vitamins are generally well-absorbed and do not require restriction in chronic pancreatitis.
A client is admitted with a diagnosis of ulcerative colitis. Which of the following symptoms should the nurse expect the client to report when responding to questions about his bowel elimination pattern?
- A. Constipation.
- B. Bloody, diarrheal stools.
- C. Steatorrhea.
- D. Alternating periods of constipation and diarrhea.
Correct Answer: B
Rationale: The correct answer is B: Bloody, diarrheal stools. In ulcerative colitis, inflammation of the colon leads to symptoms such as bloody diarrhea. This occurs due to ulceration and inflammation of the colon lining. The presence of blood in the stool is a hallmark symptom of ulcerative colitis. The other choices are incorrect because:
A: Constipation is not typically associated with ulcerative colitis. It is more common in conditions like irritable bowel syndrome.
C: Steatorrhea, which is fatty, greasy stools, is not a common symptom of ulcerative colitis.
D: Alternating periods of constipation and diarrhea are more indicative of conditions like irritable bowel syndrome or functional gastrointestinal disorders, not specifically ulcerative colitis.
The client with a colostomy has an order for irrigation of the colostomy. The nurse uses which solution for the irrigation?
- A. Distilled water
- B. Tap water
- C. Sterile water
- D. Lactated Ringer's
Correct Answer: B
Rationale: The correct answer is B: Tap water. Tap water is used for colostomy irrigation as it is isotonic and won't disrupt electrolyte balance. Distilled water (A) can cause electrolyte imbalances. Sterile water (C) may not be necessary, and Lactated Ringer's (D) is not typically used for colostomy irrigation.
The nurse has provided home care instructions to a client who had a subtotal gastrectomy. The nurse instructs the client regarding the signs and symptoms associated with dumping syndrome. Which of the following signs and symptoms, if identified by the client, indicates an understanding of this potential complication following gastrointestinal surgery?
- A. Hiccups and diarrhea
- B. Fatigue and abdominal pain
- C. Constipation and fever
- D. Diaphoresis and diarrhea
Correct Answer: D
Rationale: The correct answer is D: Diaphoresis and diarrhea. Diaphoresis (excessive sweating) and diarrhea are classic signs of dumping syndrome, a common complication after gastrectomy. Diaphoresis occurs due to the rapid movement of food into the intestines, triggering the release of hormones leading to sweating. Diarrhea results from the rapid emptying of undigested food into the intestines. These symptoms typically occur within 30 minutes to 3 hours after eating in dumping syndrome.
Explanation for why the other choices are incorrect:
A: Hiccups and diarrhea - Hiccups are not typically associated with dumping syndrome.
B: Fatigue and abdominal pain - Fatigue and abdominal pain are not specific symptoms of dumping syndrome.
C: Constipation and fever - Constipation and fever are not typical signs of dumping syndrome.
In summary, diaphoresis and diarrhea are classic symptoms of dumping syndrome due to rapid emptying of food into the intestines, making