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The nurse in the intensive care unit is caring for a client being treated for necrotizing pancreatitis. Which of the following findings would indicate the client is experiencing a complication?
- A. Periumbilical bruising
- B. Abdominal pain rated 5/10 on the numerical rating scale
- C. White blood cell count 13,500 mm3 [5,000-10,000 mm3]
- D. Decreased lung sounds in the left lower lung fields
Correct Answer: D
Rationale: Decreased lung sounds (D) may indicate a complication like pleural effusion or atelectasis in necrotizing pancreatitis, requiring further evaluation.
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The nurse is admitting a client newly diagnosed with acute pancreatitis. The nurse should anticipate a prescription for which medication?
- A. 3% saline infusion
- B. Fentanyl
- C. Diphenoxylate-atropine
- D. Sucralfate
Correct Answer: B
Rationale: Fentanyl is used for pain management in acute pancreatitis, which is often severe. 3% saline is not standard, diphenoxylate-atropine treats diarrhea (not a primary symptom), and sucralfate is for ulcers, not pancreatitis.
The nurse is conducting a health screening at a local health fair. Which of the following should the nurse recognize as risk factors for developing colorectal cancer? Select all that apply.
- A. Ulcerative colitis
- B. Body Mass Index (BMI) of 21
- C. Human Immunodeficiency Virus (HIV) infection
- D. Low-fiber diet
- E. Excessive alcohol consumption
- F. African-American ethnicity
Correct Answer: A,D,E,F
Rationale: Ulcerative colitis (A), low-fiber diet (D), excessive alcohol (E), and African-American ethnicity (F) are risk factors for colorectal cancer. Normal BMI (B) and HIV (C) are not directly linked.
The nurse is assessing a client with cholecystitis. To support this finding, the nurse expects the client to localize the pain in the
- A. Right upper quadrant, radiating to the right shoulder.
- B. Right upper quadrant, radiating to the left shoulder.
- C. Right lower quadrant, radiating to the pelvic bones.
- D. Right lower quadrant, radiating to the umbilicus.
Correct Answer: A
Rationale: Cholecystitis typically causes pain in the right upper quadrant radiating to the right shoulder (A) due to gallbladder inflammation and referred pain via the phrenic nerve.
The nurse cares for a client who reports dumping syndrome following gastric bypass surgery. To alleviate the symptoms of dumping syndrome, the nurse should recommend that the client. Select all that apply.
- A. Take a dose of their prescribed proton pump inhibitor immediately before meals.
- B. Stay upright for 30 minutes following eating.
- C. Eat high-fiber foods to decrease late dumping syndrome.
- D. Increase their intake of simple carbohydrates to prevent spikes in blood sugar.
- E. Eat five to six small meals a day to avoid overloading the stomach.
Correct Answer: B,C,E
Rationale: Staying upright (B), eating high-fiber foods (C), and consuming small, frequent meals (E) slow gastric emptying, reducing dumping syndrome symptoms. PPIs (A) are unrelated, and simple carbohydrates (D) worsen symptoms.
The nurse is caring for a client with suspected bowel perforation. Which of the following would be contraindicated?
- A. Administering gastrografin for an upper GI x-ray.
- B. An exploratory laparotomy procedure.
- C. Administering milk of magnesia following an upper GI study.
- D. An abdominal CT scan.
Correct Answer: C
Rationale: Milk of magnesia (C) is contraindicated in suspected bowel perforation as it may worsen the condition by increasing intestinal motility or causing further leakage. Gastrografin (A), laparotomy (B), and CT scans (D) are appropriate diagnostic or therapeutic measures.