Nokea
The nurse is caring for a client who is having a liver biopsy. Which positioning should the nurse place the client in immediately following the procedure?
- A. Supine
- B. Right lateral
- C. Sitting position with legs dangling off the edge of the bed
- D. Left lateral
Correct Answer: B
Rationale: Right lateral positioning (B) applies pressure to the biopsy site, minimizing bleeding risk post-liver biopsy.
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The emergency department (ED) nurse is caring for a 45-year-old male client.
Item 4 of 6
Orders
0600
• Cardiac monitoring
• NPO
• CBC
• CMP
• LFTs
• Amylase
• Lipase
• CT abdomen with contrast
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.
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.
The nurse anticipates an order to administer intravenous ..................in order to............
- A. Plasma colloid expander
- B. Hypertonic saline
- C. Isotonic crystalloid
- D. Reduce pulmonary edema
- E. Decrease electrolyte toxicity
- F. Replace fluid loss from third spacing
Correct Answer: C,F
Rationale: Isotonic crystalloid (C), such as Lactated Ringer's, is used to replace fluid loss from third spacing (F) in acute pancreatitis, addressing hypovolemia due to inflammation and fluid shifts.
The nurse cares for a client four days postoperative following an open splenectomy. The client's vital signs are T 101.1°F (38.4°C), P 92, RR 17, BP 152/86, and pulse oximetry reading 95% on oxygen at 2 L/min via nasal cannula. The surgical wound is assessed to have erythema and purulent drainage. The nurse should take which actions? Select all that apply.
- A. Request an order for an antibiotic
- B. Notify the physician
- C. Ambulate the client to the bedside chair
- D. Obtain an order for blood cultures
- E. Increase the nasal cannula oxygen to 4 L/minute
Correct Answer: A,B,D
Rationale: Fever, erythema, and purulent drainage suggest infection, requiring notifying the physician (B), requesting antibiotics (A), and obtaining blood cultures (D). Ambulation (C) and increasing oxygen (E) are not indicated.
The nurse is conducting a telephone call following up with a client with a colostomy placed two weeks ago. Select the findings reported by the client that require follow-up by the nurse.
- A. The client reports that he has no pain at the stoma.
- B. He states that the stoma is red and moist.
- C. He reports changing the appliance daily
- D. He reports using moisturizing soap around the stoma.
- E. The client notes that he empties the pouch when it is one-half to one-third full of stool.
- F. The client stated that his stoma has been getting smaller in size since surgery.
Correct Answer: C,D
Rationale: Changing the appliance daily (C) may indicate improper fit or skin irritation, requiring assessment. Using moisturizing soap (D) can interfere with appliance adhesion and cause skin issues, necessitating education on proper skin care.
The nurse is teaching a client about their newly established colostomy. Which of the following statements by the client would require follow-up?
- A. I will call my primary healthcare provider (PHCP) immediately if my stoma becomes bluish.
- B. I should slowly introduce high-fiber foods in my diet.
- C. I must always wear a pouch over my stoma.
- D. I should clean the skin around my stoma with rubbing alcohol.
Correct Answer: D
Rationale: Using rubbing alcohol (D) can irritate the skin around the stoma. Options A, B, and C are appropriate for colostomy care.
A client recently diagnosed with peptic ulcer disease is being discharged. While the nurse provides discharge teaching, which of the following over-the-counter medications should the client be instructed to avoid?
- A. Calcium
- B. Magnesium
- C. Sodium
- D. Aspirin
Correct Answer: D
Rationale: Aspirin can irritate the gastric mucosa and increase the risk of bleeding in peptic ulcer disease. Calcium, magnesium, and sodium (in typical OTC forms) do not typically exacerbate ulcers.