Nokea
A patient is being treated on the acute medical unit for acute pancreatitis. The nurse has identified a diagnosis of Ineffective Breathing Pattern Related to Pain. What intervention should the nurse perform in order to best address this diagnosis?
- A. Position the patient supine to facilitate diaphragm movement.
- B. Administer corticosteroids by nebulizer as ordered.
- C. Perform oral suctioning as needed to remove secretions.
- D. Maintain the patient in a semi-Fowlers position whenever possible.
Correct Answer: D
Rationale: The nurse maintains the patient in a semi-Fowlers position to decrease pressure on the diaphragm by a distended abdomen and to increase respiratory expansion. A supine position will result in increased pressure on the diaphragm and potentially decreased respiratory expansion. Steroids and oral suctioning are not indicated.
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A patient has been scheduled for an ultrasound of the gallbladder the following morning. What should the nurse do in preparation for this diagnostic study?
- A. Have the patient refrain from food and fluids after midnight.
- B. Administer the contrast agent orally 10 to 12 hours before the study.
- C. Administer the radioactive agent intravenously the evening before the study.
- D. Encourage the intake of 64 ounces of water 8 hours before the study.
Correct Answer: A
Rationale: An ultrasound of the gallbladder is most accurate if the patient fasts overnight, so that the gallbladder is distended. Contrast and radioactive agents are not used when performing ultrasonography of the gallbladder, as an ultrasound is based on reflected sound waves.
A student nurse is caring for a patient who has a diagnosis of acute pancreatitis and who is receiving parenteral nutrition. The student should prioritize which of the following assessments?
- A. Fluid output
- B. Oral intake
- C. Blood glucose levels
- D. BUN and creatinine levels
Correct Answer: C
Rationale: In addition to administering enteral or parenteral nutrition, the nurse monitors serum glucose levels every 4 to 6 hours. Output should be monitored but in most cases it is not more important than serum glucose levels. A patient on parenteral nutrition would have no oral intake to monitor. Blood sugar levels are more likely to be unstable than indicators of renal function.
A patient has had a laparoscopic cholecystectomy. The patient is now complaining of right shoulder pain. What should the nurse suggest to relieve the pain?
- A. Aspirin every 4 to 6 hours as ordered
- B. Application of heat 15 to 20 minutes each hour
- C. Application of an ice pack for no more than 15 minutes
- D. Application of liniment rub to affected area
Correct Answer: B
Rationale: If pain occurs in the right shoulder or scapular area (from migration of the CO2 used to insufflate the abdominal cavity during the procedure), the nurse may recommend use of a heating pad for 15 to 20 minutes hourly, walking, and sitting up when in bed. Aspirin would constitute a risk for bleeding.
A 55-year-old man has been newly diagnosed with acute pancreatitis and admitted to the acute medical unit. How should the nurse most likely explain the pathophysiology of this patients health problem?
- A. Toxins have accumulated and inflamed your pancreas.
- B. Bacteria likely migrated from your intestines and became lodged in your pancreas.
- C. A virus that was likely already present in your body has begun to attack your pancreatic cells.
- D. The enzymes that your pancreas produces have damaged the pancreas itself.
Correct Answer: D
Rationale: Although the mechanisms causing pancreatitis are unknown, pancreatitis is commonly described as the autodigestion of the pancreas. Less commonly, toxic substances and microorganisms are implicated as the cause of pancreatitis.
A patient is admitted to the unit with acute cholecystitis. The physician has noted that surgery will be scheduled in 4 days. The patient asks why the surgery is being put off for a week when he has a sick gallbladder. What rationale would underlie the nurses response?
- A. Surgery is delayed until the patient can eat a regular diet without vomiting.
- B. Surgery is delayed until the acute symptoms subside.
- C. The patient requires aggressive nutritional support prior to surgery.
- D. Time is needed to determine whether a laparoscopic procedure can be used.
Correct Answer: B
Rationale: Unless the patients condition deteriorates, surgical intervention is delayed just until the acute symptoms subside (usually within a few days). There is no need to delay surgery pending an improvement in nutritional status, and deciding on a laparoscopic approach is not a lengthy process.