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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.
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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.
After receiving change-of-shift report, which of the following patients should the nurse assess first?
- A. 50-year-old with persistent pancreatitis who has gnawing abdominal pain
- B. 48-year-old who has compensated cirrhosis and is complaining of anorexia
- C. 45-year-old with cirrhosis and severe ascites who has an oral temperature of 38.8°C (101.8°F)
- D. 36-year-old who is recovering from a laparoscopic cholecystectomy and has severe shoulder pain
Correct Answer: C
Rationale: This patient's history and fever suggest spontaneous bacterial peritonitis, which would require rapid assessment and interventions such as antibiotic therapy. The clinical manifestations for the other patients are consistent with their diagnoses and do not indicate complications are occurring.
Which of the following actions should be included in the plan of care for a patient who has recently been diagnosed with asymptomatic non-alcoholic fatty liver disease (NAFLD)?
- A. Teach symptoms of variceal bleeding
- B. Review the patient's current medication list.
- C. Draw blood for hepatitis serology testing.
Correct Answer: C
Rationale: Reviewing the patient's current medication list is essential to identify potential hepatotoxic drugs and manage risk factors like diabetes or hyperlipidemia, which are associated with NAFLD progression. Teaching about variceal bleeding is irrelevant for asymptomatic NAFLD, as varices are a complication of advanced liver disease. Hepatitis serology is not indicated unless viral hepatitis is suspected.
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 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.