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The nurse is caring for a patient with acute pancreatitis who has a nasogastric (NG) tube to suction and is NPO. Which of the following information obtained by the nurse indicates that these therapies have been effective?
- A. Bowel sounds are present.
- B. Grey Turner sign resolves.
- C. Electrolyte levels are normal.
- D. Abdominal pain is decreased.
Correct Answer: D
Rationale: NG suction and NPO status will decrease the release of pancreatic enzymes into the pancreas and decrease pain. Although bowel sounds may be hypotonic with acute pancreatitis, the presence of bowel sounds does not indicate that treatment with NG suction and NPO status have been effective. Electrolyte levels will be abnormal with NG suction and must be replaced by appropriate IV infusion. Although Grey Turner sign will eventually resolve, it would not be appropriate to wait for this to occur to determine whether treatment was effective.
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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 caring for a patient following an incisional cholecystectomy for cholelithiasis. Which of the following actions is priority for the nurse to implement?
- A. Patient education about low-fat food choices.
- B. Perform leg exercises hourly while awake.
- C. Ambulate the evening of the operative day.
- D. Turn, cough, and deep breathe every 2 hours.
Correct Answer: D
Rationale: Postoperative nursing care for incisional cholecystectomy is the same as general postoperative nursing care. Postoperative nursing care after a cholecystectomy focuses on prevention of respiratory complications because the surgical incision is high in the abdomen and impairs coughing and deep breathing. The other nursing actions also are important to implement but are not as high a priority as ensuring adequate ventilation.
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.
The nurse is admitting a patient to the emergency department with pancreatitis who has been vomiting blood. Which of the following actions should the nurse take first?
- A. Insert a large-gauge IV catheter.
- B. Draw blood for coagulation studies.
- C. Check BP, heart rate, and respirations.
- D. Place the patient in the supine position.
Correct Answer: C
Rationale: The nurse's first action should be to determine the patient's hemodynamic status by assessing vital signs. Drawing blood for coagulation studies and inserting an IV catheter also are appropriate. However, the vital signs may indicate the need for more urgent actions. Since aspiration is a concern for this patient, the nurse will need to assess the patient's vital signs and neurological status before placing the patient in the supine position.
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.