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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.
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A nurse plans care for a client who has acute pancreatitis and is prescribed nothing by mouth (NPO). With which health care team members should the nurse collaborate to provide appropriate nutrition to the client? (Select all that apply.)
- A. Registered dietitian
- B. Nursing assistant
- C. Clinical pharmacist
- D. Certified herbalist
- E. Health care provider
Correct Answer: A,C,E
Rationale: Clients who are prescribed NPO while experiencing an acute pancreatitis episode may need enteral or parenteral nutrition. The nurse should collaborate with the registered dietitian, clinical pharmacist, and health care provider to determine the best nutritional intervention. The nursing assistant and certified herbalist would not assist with this clinical decision.
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.
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 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 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.