Nokea
The nurse is taking a hospital admission history for the 40-year-old client. The nurse is concerned about possible acute pancreatitis when the client makes which statement?
- A. “I have sudden-onset intense pain in my upper left abdomen that goes to my back.”
- B. “I had persistent lower abdominal pain that now shifted to the lower right quadrant.”
- C. “My stools are loose and bloody, and I have cramping abdominal pain with spasms.”
- D. “I have this mild pain in my upper abdomen, but I have been vomiting forcefully a lot.”
Correct Answer: A
Rationale: A. The predominant symptom of acute pancreatitis is severe, deep or piercing, continuous or steady abdominal pain in the upper left quadrant. The pain may radiate to the back because of the retroperitoneal location of the pancreas. Middle-aged individuals are at increased risk for developing acute pancreatitis. B. Abdominal pain located mainly in the right lower quadrant may be a symptom of appendicitis (not pancreatitis). Appendicitis is more common in younger adults. C. Bloody diarrhea and colicky abdominal pain are symptoms of IBD, also more common in young adults. D. Upper abdominal pain and projectile vomiting are symptoms of gastric outlet obstruction or another GI disorder and not pancreatitis.
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The client presents with a complete blockage of the large intestine from a tumor. Which healthcare provider's order would the nurse question?
- A. Obtain consent for a colonoscopy and biopsy.
- B. Start an IV of 0.9% saline at 125 mL/hr.
- C. Administer 3 liters of GoLYTELY.
- D. Give tap water enemas until it is clear.
Correct Answer: C
Rationale: GoLYTELY, a bowel prep, is contraindicated in complete bowel obstruction, as it could worsen the condition or cause perforation. Colonoscopy, IV fluids, and enemas (if cautious) may be appropriate depending on the clinical plan.
The client with cirrhosis is scheduled for a transjugular intrahepatic portosystemic shunt (TIPS) placement. The nurse realizes the client does not understand the procedure when the client makes which statement?
- A. “I hope the abdominal incision heals fast after this procedure so I can return home.”
- B. “My risk of bleeding from my esophagus again should be decreased after this procedure.”
- C. “The shunt they are placing could become occluded in the future; I hope it doesn’t happen.”
- D. “This procedure should keep me from getting so much fluid buildup in my abdomen.”
Correct Answer: A
Rationale: A. This statement indicates the client does not understand the procedure. There is no need for an abdominal incision. The TIPS is placed through the jugular vein and threaded down to the hepatic vein. B. The TIPS procedure will decrease pressure in the portal vein and thus decrease the risk of bleeding from esophageal varices. C. There is a risk that the stent that is placed will become occluded. D. The shunt will decrease ascites formation.
The nurse is preparing to care for the client immediately after a Whipple procedure. The nurse should plan to include which action?
- A. Monitor the blood glucose levels
- B. Administer enteral feedings
- C. Irrigate the NG tube with 30 mL of saline
- D. Assist with bowel elimination within 8 hours of surgery
Correct Answer: A
Rationale: A. The Whipple procedure induces insulin-dependent diabetes because the proximal pancreas is resected. Thus, the blood glucose levels should be monitored closely starting immediately after surgery. B. Parenteral (not enteral) feedings are the method of choice for providing nutrition immediately after surgery. C. The NG tube is strategically placed during surgery and should not be irrigated without a surgeon’s order. With an order, gentle irrigation with 10 to 20 mL of NS is appropriate. D. Since this surgery reshapes the GI tract, the client will not have peristalsis and bowel movements for several days.
The client diagnosed with end-stage liver failure is admitted with esophageal bleeding. The HCP inserts and inflates a triple-lumen nasogastric tube (Sengstaken-Blakemore). Which nursing intervention should the nurse implement for this treatment?
- A. Assess the gag reflex every shift.
- B. Stay with the client at all times.
- C. Administer the laxative lactulose (Chronulac).
- D. Monitor the client's ammonia level.
Correct Answer: B
Rationale: The Sengstaken-Blakemore tube can dislodge or cause complications like aspiration, requiring constant monitoring. Gag reflex, lactulose, and ammonia are unrelated to this intervention.
The nurse is teaching a class on diverticulosis. Which interventions should the nurse discuss when teaching ways to prevent an acute exacerbation of diverticulosis?
- A. Eat a high-fiber diet.
- B. Increase fluid intake.
- C. Elevate the HOB after eating.
- D. Walk 30 minutes a day.
- E. Take an antacid every two (2) hours.
Correct Answer: A,B,D
Rationale: High-fiber diet, increased fluids, and regular exercise (e.g., walking) prevent constipation and reduce pressure in diverticula, lowering exacerbation risk. Elevating the HOB and antacids are unrelated to diverticulosis prevention.