Nokea
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.
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The nurse is performing discharge teaching for a client diagnosed with Cushing's disease. Which statement by the client demonstrates an understanding of the instructions?
- A. I will be sure to notify my health-care provider if I start to run a fever.
- B. Before I stop taking the prednisone, I will be taught how to taper it off.
- C. If I get weak and shaky, I need to eat some hard candy or drink some juice.
- D. It is fine if I continue to participate in weekend games of tackle football.
Correct Answer: B
Rationale: Tapering prednisone prevents adrenal crisis, indicating understanding. Fever notification is general, hypoglycemia is unrelated, and tackle football is unsafe.
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.
Twelve hours after a transsphenoidal hypophysectomy, the client keeps clearing his throat and complains of a drip in his mouth. To accurately assess this, the nurse should test the fluid for:
- A. sugar.
- B. protein.
- C. bacteria.
- D. blood.
Correct Answer: A
Rationale: A post-nasal drip post-transsphenoidal hypophysectomy may indicate cerebrospinal fluid (CSF) leakage, which contains glucose (sugar), unlike saliva or mucus.
When the nurse teaches the client how to self-administer potassium iodide (Lugol's solution), which instruction is most appropriate?
- A. Swallow the drug quickly.
- B. Take the drug before meals.
- C. Dilute the drug in fruit juice.
- D. Chill the drug before taking it.
Correct Answer: C
Rationale: Diluting potassium iodide in fruit juice improves palatability and reduces gastric irritation.
The client with an acute exacerbation of chronic pancreatitis has a nasogastric (N/G) tube. Which interventions should the nurse implement? Select all that apply.
- A. Monitor the client's bowel sounds.
- B. Monitor the client's food intake.
- C. Assess the client's intravenous site.
- D. Provide oral and nasal care.
- E. Monitor the client's blood glucose.
Correct Answer: A,C,D,E
Rationale: Monitoring bowel sounds, IV site, oral/nasal care, and glucose manage NG tube complications and pancreatitis-related risks (e.g., hyperglycemia). Food intake is irrelevant with NPO status.