Nokea
The nurse is assessing a client diagnosed with necrotizing pancreatitis. Which of the following assessment findings would be expected?
- A. Ecchymotic discoloration in the periumbilical region
- B. Dysuria
- C. Hyperactive bowel sounds
- D. Hematuria
Correct Answer: A
Rationale: Ecchymotic discoloration in the periumbilical region (A), known as Cullen's sign, is expected in necrotizing pancreatitis due to retroperitoneal hemorrhage.
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The nurse is caring for a client who is receiving prescribed metoclopramide for gastroparesis. Which of the following findings require immediate notification to the primary healthcare provider (PHCP)?
- A. Muscle rigidity of the neck
- B. Hyperactive bowel sounds
- C. Frequent diarrhea
- D. Abdominal distention
Correct Answer: A
Rationale: Muscle rigidity of the neck (dystonia) is a serious extrapyramidal side effect of metoclopramide, requiring immediate PHCP notification. Hyperactive bowel sounds, diarrhea, and distention are less urgent or expected with gastroparesis.
A nurse is assigned to care for a client with liver dysfunction and ascites and is ordered to measure the client's abdominal girth daily. To ensure accuracy, the nurse should utilize which landmark?
- A. Xiphoid process
- B. Umbilicus
- C. Iliac crest
- D. Symphysis pubis
Correct Answer: B
Rationale: The umbilicus (B) is a consistent anatomical landmark for measuring abdominal girth in ascites, ensuring accurate and reproducible measurements.
The primary healthcare provider (PHCP) prescribes the insertion of a nasogastric tube for a client with paralytic ileus. This action is appropriate and does not require follow-up. The nurse understands that the primary purpose of placing this tube is to
- A. Feed the client.
- B. Decompress the stomach.
- C. Irrigate the stomach.
- D. Administer medications.
Correct Answer: B
Rationale: A nasogastric tube in paralytic ileus (B) decompresses the stomach, relieving distention and preventing complications like aspiration.
The emergency department (ED) nurse is caring for a 45-year-old male client.
Item 5 of 6
Laboratory & Imaging Results
0630
Exam: CT Abdomen and Pelvis with IV Contrast
Indication: Acute onset of epigastric abdominal pain, nausea, vomiting.
Findings:
Pancreas: Diffuse enlargement of the pancreas with heterogeneous enhancement. Peripancreatic fat stranding and inflammatory changes are present, most pronounced around the pancreatic head and body. No evidence of necrosis at this time. No discrete mass or cystic lesion noted. Biliary system: Gallbladder is distended with no wall thickening or pericholecystic fluid. No gallstones visualized. Common bile duct is normal in caliber (~5 mm). Liver, spleen, kidneys, and adrenal glands: Normal in appearance. No focal lesions. Bowel: No obstruction or bowel wall thickening noted.
Impression:
Imaging findings are consistent with acute interstitial edematous pancreatitis.
No evidence of pancreatic necrosis or pseudocyst formation at this time.
Nurses’ Notes
0600: The client reports sudden, severe epigastric pain. He has a history of chronic alcohol use disorder (30+ years), GERD, and hypertension. His home medications include pantoprazole and lisinopril. Upon assessment, the client is noted to be alert and oriented x4. He is mildly diaphoretic, with pulses 2+ and regular. Abdomen is distended, guarding on palpation, diminished bowel sounds, and no stool in the last 24 hours. He reports nausea and vomiting, and his pain is worse after eating fatty foods, rated 7/10 and radiating to his back. Breath sounds slightly diminished bilaterally, no adventitious sounds, denies cough or dyspnea. He reports heavy alcohol intake two days ago. Fingerstick glucose is 145 mg/dL (8.06 mmol/L) [70-110 mg/dL; 4-6 mmol/L]. Temperature is 101.3°F (38.5°C), heart rate of 112 bpm, respiratory rate of 24 breaths/min, blood pressure of 98/64 mmHg, and oxygen saturation of 95% on room air.
0630: Physician confirmed the diagnosis of acute pancreatitis based on clinical presentation, laboratory findings, and imaging studies.
1030: Client receiving LR at 150 mL/hr, calcium replacement completed. Urine output over the last 4 hours is 80 mL of dark amber urine. The client reports increased thirst. The abdomen continues to be distended with diminished bowel sounds. He reports that nausea has improved after receiving PRN medication. Increased edema noted in the lower extremities.
Orders
0630
• Ondansetron 4mg IV q6h PRN
• Calcium gluconate 2g IV over 5-10 minutes
• Lactated Ringer’s solution continuous infusion IV rate of 150mL/hr
The nurse is preparing interventions to address the client's needs. Select the four (4) nursing interventions that should be prioritized based on the client's current condition.
- A. Notify the provider of the client's urine output
- B. Maintain NPO status
- C. Place the client in the Trendelenburg position
- D. Request an order for an indwelling urinary catheter
- E. Begin continuous cardiac monitoring
- F. Insert a nasogastric tube for gastric decompression
- G. Educate the client about initiating a low-fat diet
Correct Answer: A,B,D,E
Rationale: Low urine output (A) indicates possible hypovolemia, requiring provider notification. NPO status (B) prevents pancreatic stimulation. An indwelling catheter (D) monitors fluid balance accurately. Cardiac monitoring (E) is needed due to tachycardia and hypotension. Trendelenburg (C) is not indicated, and a low-fat diet (G) is premature.
The nurse has just finished assisting the physician in performing a paracentesis. What should be the priority nursing intervention following the procedure?
- A. Administer analgesics to control pain
- B. Monitor for signs of infection
- C. Monitor for signs of hypovolemia
- D. Ensure that the ascitic fluid is sent to the lab for analysis
Correct Answer: C
Rationale: Monitoring for hypovolemia (C) is critical after paracentesis due to the risk of fluid shifts from removing large volumes of ascitic fluid.