Nokea
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.
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The nurse is preparing a teaching plan for a young adult patient who is diagnosed with early alcoholic cirrhosis. Which of the following topics is most important to include in patient teaching?
- A. Need to abstain from alcohol
- B. Use of vitamin B supplements
- C. Maintenance of a nutritious diet
- D. Treatment with lactulose
Correct Answer: A
Rationale: The disease progression can be stopped or reversed by alcohol abstinence. The other interventions may be used when cirrhosis becomes more severe to decrease symptoms or complications, but the priority for this patient is to stop the progression of the disease.
The nurse is caring for a patient with cirrhosis who has 4+ pitting edema of the feet and legs. Which of the following assessments is priority for the nurse to monitor?
- A. Hemoglobin
- B. Temperature
- C. Activity level
- D. Albumin
Correct Answer: D
Rationale: The low oncotic pressure caused by hypoalbuminemia is a major pathophysiological factor in the development of edema. The other parameters also should be monitored, but they are not directly associated with the patient's current symptoms.
The nurse is caring for a patient who has had a transjugular intrahepatic portosystemic shunt (TIPS) placement. Which of the following indicate that the procedure has been effective?
- A. Lower indirect bilirubin level
- B. Increase in serum albumin level
- C. Decrease in episodes of variceal bleeding
- D. Improvement in alertness and orientation
Correct Answer: C
Rationale: TIPS is used to lower pressure in the portal venous system and decrease the risk of bleeding from esophageal varices. Indirect bilirubin level and serum albumin levels are not affected by shunting procedures. TIPS will increase the risk for hepatic encephalopathy.
The nurse is obtaining a health history from a patient with acute pancreatitis. Which of the following information should the nurse specifically assess when conducting a health history?
- A. Alcohol use
- B. Diabetes mellitus
- C. High-protein diet
- D. Cigarette smoking
Correct Answer: A
Rationale: Alcohol use is one of the most common risk factors for pancreatitis in Canada. In Canada, the most common cause is gallbladder disease (gallstones) followed by alcoholism. Cigarette smoking, diabetes, and high-protein diets are not risk factors.
The nurse is taking the BP of a patient with severe acute pancreatitis and notices carpal spasm of the patient's hand. Which of the following actions should the nurse take next?
- A. Ask the patient about any arm pain.
- B. Retake the patient blood pressure.
- C. Check the calcium level on the chart.
- D. Notify the health care provider immediately.
Correct Answer: C
Rationale: The patient with acute pancreatitis is at risk for hypocalcemia, and the assessment data indicate a positive Trousseau's sign. The health care provider should be notified after the nurse checks the patient's calcium level. There is no indication that the patient needs to have the BP rechecked or that there is any arm pain.