Nokea
The health care provider plans a paracentesis for a patient with ascites caused by liver cancer. Which of the following actions should the nurse implement to prepare the patient for the procedure?
- A. Place the patient on NPO status
- B. Assist the patient to lie flat in bed.
- C. Ask the patient to empty the bladder.
- D. Position the patient on the right side.
Correct Answer: C
Rationale: The patient should empty the bladder to decrease the risk of bladder perforation during the procedure. The patient would be positioned in Fowler's position and would not be able to lie flat without compromising breathing. Since no sedation is required for paracentesis, the patient does not need to be NPO.
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The nurse is caring for a patient with acute pancreatitis who has a nasogastric (NG) tube to suction and is NPO. Which of the following information obtained by the nurse indicates that these therapies have been effective?
- A. Bowel sounds are present.
- B. Grey Turner sign resolves.
- C. Electrolyte levels are normal.
- D. Abdominal pain is decreased.
Correct Answer: D
Rationale: NG suction and NPO status will decrease the release of pancreatic enzymes into the pancreas and decrease pain. Although bowel sounds may be hypotonic with acute pancreatitis, the presence of bowel sounds does not indicate that treatment with NG suction and NPO status have been effective. Electrolyte levels will be abnormal with NG suction and must be replaced by appropriate IV infusion. Although Grey Turner sign will eventually resolve, it would not be appropriate to wait for this to occur to determine whether treatment was effective.
The nurse is admitting a patient with acute bleeding from esophageal varices who asks the nurse the purpose for the ordered pantoprazole. Which of the following responses by the nurse is best?
- A. The medication will reduce the risk for aspiration.
- B. The medication will decrease nausea and anorexia.
- C. The medication will inhibit the development of gastric ulcers.
- D. The medication will prevent irritation to the esophageal varices.
Correct Answer: D
Rationale: Pantoprazole is a proton pump inhibitor. Supportive measures during an acute variceal bleed include administration of fresh-frozen plasma and packed red blood cells, vitamin K, and proton pump inhibitors. Although pantoprazole does decrease the risk for peptic ulcers, reduce nausea, and help prevent aspiration pneumonia, these are not the primary purpose for its use in this patient.
Which of the following nursing actions should be included in the plan of care for a patient who is being treated for bleeding esophageal varices with balloon tamponade using a device such as a Blakemore tube?
- A. Monitor the patient for shortness of breath.
- B. Encourage the patient to cough every 4 hours.
- C. Deflate the gastric balloon every 12 hours.
- D. Verify the position of the balloon every 6 hours.
Correct Answer: A
Rationale: A common complication of balloon tamponade is occlusion of the airway by the balloon, so it is important to monitor the patient's respiratory status. In addition, if the gastric balloon ruptures, the esophageal balloon may slip upward and occlude the airway. Coughing increases the pressure on the varices and increases the risk for bleeding. Balloon position is verified after insertion and does not require further verification. The esophageal balloon is deflated every 8-12 hours to avoid necrosis, but if the gastric balloon is deflated, the esophageal balloon may occlude the airway.
The nurse is caring for a patient who has advanced cirrhosis and is receiving lactulose. Which of the following findings by the nurse indicates that the medication is effective?
- A. The patient is alert and oriented.
- B. The patient denies nausea or anorexia.
- C. The patient's bilirubin level decreases.
- D. The patient has at least one stool daily.
Correct Answer: A
Rationale: The purpose for lactulose in the patient with cirrhosis is to lower ammonia levels and prevent encephalopathy. Although lactulose may be used to treat constipation, that is not the purpose for this patient. Lactulose will not decrease nausea and vomiting or lower bilirubin levels.
The nurse is caring for a patient with severe cirrhosis who has an episode of bleeding esophageal varices. Which of the following laboratory tests should the nurse monitor to detect possible complications of the bleeding episode?
- A. Bilirubin
- B. Ammonia
- C. Potassium
- D. Prothrombin time
Correct Answer: B
Rationale: The blood in the gastrointestinal (GI) tract will be absorbed as protein and may result in an increase in ammonia level because the liver cannot metabolize protein well. The prothrombin time, bilirubin, and potassium levels also should be monitored, but these will not be affected by the bleeding episode.