Nokea
The client diagnosed with acute pancreatitis has a ruptured pseudocyst. Which procedure should the nurse anticipate the HCP prescribing?
- A. Paracentesis.
- B. Chest tube insertion.
- C. Lumbar puncture.
- D. Biopsy of the pancreas.
Correct Answer: A
Rationale: A ruptured pancreatic pseudocyst can cause peritoneal irritation or fluid accumulation, potentially requiring drainage. Paracentesis removes abdominal fluid, which may be performed in severe cases, though surgical drainage or endoscopic intervention is more specific. Chest tube insertion is for pleural issues, lumbar puncture is for cerebrospinal fluid, and pancreatic biopsy is diagnostic, not therapeutic for a ruptured pseudocyst.
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The nurse knows the diabetic client understands what 'free' foods on the exchange list means if the client excludes which one of the following from a meal plan?
- A. Iced tea
- B. Flavored water
- C. Light beer
- D. Club soda
Correct Answer: C
Rationale: Light beer contains carbohydrates and calories, unlike free foods such as iced tea, flavored water, and club soda.
The nurse is caring for the client who is experiencing symptoms associated with pheochromocytoma. Which intervention should be included in the plan of care for this client?
- A. Offer distractions such as television or music.
- B. Encourage family and friends to visit often.
- C. Assist with ambulation at least three times a day.
- D. Administer nicardipine for hypertension.
Correct Answer: D
Rationale: Nicardipine controls hypertension caused by excess catecholamines in pheochromocytoma.
The nurse is planning a program for clients at a health fair regarding the prevention and early detection of cancer of the pancreas. Which self-care activity should the nurse discuss as an example of a primary nursing intervention?
- A. Monitor for elevated blood glucose at random intervals.
- B. Inspect the skin and sclera of the eyes for a yellow tint.
- C. Limit meat in the diet and eat a diet low in fat.
- D. Instruct the client with hyperglycemia about insulin injections.
Correct Answer: C
Rationale: A low-fat diet reduces pancreatic stress, a primary prevention strategy. Glucose monitoring, jaundice inspection, and insulin teaching are secondary or tertiary.
The UAP on the medical floor tells the nurse the client diagnosed with DKA wants something else to eat for lunch. Which intervention should the nurse implement?
- A. Instruct the UAP to get the client additional food.
- B. Notify the dietitian about the client's request.
- C. Request the HCP increase the client's caloric intake.
- D. Tell the UAP the client cannot have anything else.
Correct Answer: B
Rationale: Notifying the dietitian ensures the client’s nutritional needs are met within DKA dietary restrictions. Additional food, caloric increases, or denial are inappropriate without consultation.
The client diagnosed with cancer of the head of the pancreas is two (2) days postpancreatoduodenectomy (Whipple's procedure). Which nursing problem has the highest priority?
- A. Anticipatory grieving.
- B. Fluid volume imbalance.
- C. Alteration in comfort.
- D. Altered nutrition.
Correct Answer: B
Rationale: Fluid volume imbalance is the priority post-Whipple’s due to risks of bleeding or dehydration, impacting stability. Grieving, pain, and nutrition are secondary.