Nokea
The nurse is admitting a patient with acute cholecystitis. Which of the following findings is most important for the nurse to report to the health care provider?
- A. The patient's urine is bright yellow.
- B. The patient's stools are clay coloured.
- C. The patient complains of persistent heartburn.
- D. The patient has an increase in pain after eating.
Correct Answer: B
Rationale: The clay-coloured stools indicate biliary obstruction, which requires rapid intervention to resolve. The other data are not unusual for a patient with this diagnosis, although the nurse also would report the other assessment information to the health care provider.
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Which of the following patients should alert the nurse that screening for hepatitis C should be done?
- A. The patient eats frequent meals in fast-food restaurants.
- B. The patient recently travelled to an undeveloped country.
- C. The patient had a blood transfusion after surgery in 1999.
- D. The patient reports a one-time use of IV drugs 20 years ago.
Correct Answer: D
Rationale: Any patient with a history of IV drug use should be tested for hepatitis C. Blood transfusions given after 1992, when an antibody test for hepatitis C became available, do not pose a risk for hepatitis C. Hepatitis C is not spread by the oral-fecal route and therefore is not caused by contaminated food or by travelling in underdeveloped countries.
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.
Which of the following assessment findings in a patient with acute pancreatitis should the nurse report urgently to the health care provider?
- A. Nausea and vomiting
- B. Hypotonic bowel sounds
- C. Abdominal tenderness and guarding
- D. Muscle twitching and finger numbness
Correct Answer: D
Rationale: Muscle twitching and finger numbness indicate hypocalcemia, which may lead to tetany unless calcium gluconate is administered. Numbness or tingling around the lips and in the fingers is an early indicator of hypocalcemia. Although the other findings also should be reported to the health care provider, they do not indicate complications that require rapid action.
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.
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.