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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.
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The nurse is caring for a patient who has just returned from the ERCP removal of gallstones. The nurse should monitor the patient for signs of what complications?
- A. Pain and peritonitis
- B. Bleeding and perforation
- C. Acidosis and hypoglycemia
- D. Gangrene of the gallbladder and hyperglycemia
Correct Answer: B
Rationale: Following ERCP removal of gallstones, the patient is observed closely for bleeding, perforation, and the development of pancreatitis or sepsis. Blood sugar alterations, gangrene, peritonitis, and acidosis are less likely complications.
A 37-year-old male patient presents at the emergency department (ED) complaining of nausea and vomiting and severe abdominal pain. The patients abdomen is rigid, and there is bruising to the patients flank. The patients wife states that he was on a drinking binge for the past 2 days. The ED nurse should assist in assessing the patient for what health problem?
- A. Severe pancreatitis with possible peritonitis
- B. Acute cholecystitis
- C. Chronic pancreatitis
- D. Acute appendicitis with possible perforation
Correct Answer: A
Rationale: Severe abdominal pain is the major symptom of pancreatitis that causes the patient to seek medical care. Pain in pancreatitis is accompanied by nausea and vomiting that does not relieve the pain or nausea. Abdominal guarding is present and a rigid or board-like abdomen may be a sign of peritonitis. Ecchymosis (bruising) to the flank or around the umbilicus may indicate severe peritonitis. Pain generally occurs 24 to 48 hours after a heavy meal or alcohol ingestion. The link with alcohol intake makes pancreatitis a more likely possibility than appendicitis or cholecystitis.
The family of a patient in the ICU diagnosed with acute pancreatitis asks the nurse why the patient has been moved to an air bed. What would be the nurses best response?
- A. Air beds allow the care team to reposition her more easily while shes on bed rest.
- B. Air beds are far more comfortable than regular beds and shell likely have to be on bed rest a long time.
- C. The bed automatically moves, so shes less likely to develop pressure sores while shes in bed.
- D. The bed automatically moves, so she is likely to have less pain.
Correct Answer: C
Rationale: It is important to turn the patient every 2 hours; use of specialty beds may be indicated to prevent skin breakdown. The rationale for a specialty bed is not related to repositioning, comfort, or ease of movement.
A patient has undergone a laparoscopic cholecystectomy and is being prepared for discharge home. When providing health education, the nurse should prioritize which of the following topics?
- A. Management of fluid balance in the home setting
- B. The need for blood glucose monitoring for the next week
- C. Signs and symptoms of intra-abdominal complications
- D. Appropriate use of prescribed pancreatic enzymes
Correct Answer: C
Rationale: Because of the early discharge following laparoscopic cholecystectomy, the patient needs thorough education in the signs and symptoms of complications. Fluid balance is not typically a problem in the recovery period after laparoscopic cholecystectomy. There is no need for blood glucose monitoring or pancreatic enzymes.
A home health nurse is caring for a patient discharged home after pancreatic surgery. The nurse documents the nursing diagnosis Risk for Imbalanced Nutrition: Less than Body Requirements on the care plan based on the potential complications that may occur after surgery. What are the most likely complications for the patient who has had pancreatic surgery?
- A. Proteinuria and hyperkalemia
- B. Hemorrhage and hypercalcemia
- C. Weight loss and hypoglycemia
- D. Malabsorption and hyperglycemia
Correct Answer: D
Rationale: The nurse arrives at this diagnosis based on the complications of malabsorption and hyperglycemia. These complications often lead to the need for dietary modifications. Pancreatic enzyme replacement, a low-fat diet, and vitamin supplementation often are also required to meet the patients nutritional needs and restrictions. Electrolyte imbalances often accompany pancreatic disorders and surgery, but the electrolyte levels are more often deficient than excessive. Hemorrhage is a complication related to surgery, but not specific to the nutritionally based nursing diagnosis. Weight loss is a common complication, but hypoglycemia is less likely.