NUR212CH62

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Author:
TomWruble
ID:
213237
Filename:
NUR212CH62
Updated:
2013-04-16 10:14:55
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nur212e1 Care Patients Problems Biliary System Pancreas
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Description:
Care of Patients with Problems of the Biliary System and Pancreas
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  1. (62) A client is admitted to the same-day surgery unit after recovery from a laparoscopic cholecystectomy. Which action is the nurse’s priority in caring for the client?

    A. Turn the client on the right side to help the flow of bile into the drainage bag.
    B. Document the client’s use of the patient-controlled analgesia (PCA) pump.
    C. Monitor the client’s oxygen saturation level via pulse oximetry.
    D. Check that the nasogastric tube is connected to low intermittent suction.
    C. Monitor the client’s oxygen saturation level via pulse oximetry.

    The client’s oxygen saturation level should be assessed frequently until the effects of the anesthesia have passed.

    The client will not have a collection bag for bile drainage.

    An NG tube is not required during a laparoscopic cholecystectomy.

    IV pain control is usually not needed after a lapararoscopic procedure because there are only small incisions that are covered with Steri-strips and small adhesive bandages.
    (this multiple choice question has been scrambled)
  2. (62) The physician assistant prescribes pancreatic enzyme replacement capsules for a client with chronic pancreatitis. What health teaching will the nurse provide?

    A. “Take the enzymes after meals to be most effective.”
    B. “Swallow the capsule whole or with applesauce.”
    C. “Drink a full glass of milk after taking the drug.”
    D. “Crush the capsules and tablets and mix with juice.”
    B. “Swallow the capsule whole or with applesauce.”

    The client should be instructed to swallow the capsule whole if possible because of its delayed-release action.

    For greatest efficacy, PERT should be taken with meals, not before or after meals.

    They should also be taken with a full glass of water; they should not be taken with foods containing proteins, such as milk, because the enzymatic action dissolves the food into a watery substance.

    The capsules should not be crushed or chewed. If the client cannot swallow the capsule whole, its contents can be sprinkled over applesauce, mashed fruit, or rice cereal.
    (this multiple choice question has been scrambled)
  3. (62) A client has had an open Whipple procedure for pancreatic cancer. Which nursing interventions are appropriate for this client in the postoperative period? Select all that apply.

    A. Maintain IV fluids, and monitor for fluid imbalance.
    B. Assess for signs and symptoms of deep vein thrombosis.
    C. Connect the nasogastric tube to high intermittent suction.
    D. Start pancreatic enzyme replacements as soon as possible.
    E. Check finger-stick blood glucose levels regularly.
    F. Tell the client to lie flat to protect the incision.
    A, B, E

    It is important to maintain available access for TPN and fluids. Care should be taken to prevent any line sepsis.

    Clients are at risk for DVT after any surgical procedure in which extended immobility is a problem.

    The nurse should monitor for hypoglycemia or hyperglycemia due to surgical manipulation of the pancreas.

    An NG tube will be attached to low suction to prevent distention and pressure on the remaining stomach.

    PERT will be started when the client is able to take solid meals.

    The client should be placed in a semi-Fowler’s position to reduce stress on the anastomosis and suture line. This position will also aid in lung expansion.
  4. (62) A 78-year-old man is admitted from home to the medical unit with acute pancreatitis secondary to a history of gallstones, hypertension, osteoarthritis, and type 2 diabetes mellitus. He has lost 20 pounds (9.0 kg) in the past 2 months and reports severe boring-like abdominal pain, fatigue, and weakness. On physical assessment, he has decreased bowel sounds in all quadrants, crackles in the bases of his lungs, and signs of dehydration. Vital signs are: T, 100° F; P, 110; R, 36; and BP, 102/58.
    1. What is the priority for this patient’s care at this time? What current evidence supports your answer? Where would you look for current evidence that would help you answer this question? (Be specific in your answer.)

    This patient displays hypotension and tachycardia, which can indicate pancreatic hemorrhage or early signs of sepsis from toxicity because of enzymes leaking into the abdominal cavity. This patient is also at increased risk for atelectasis and pneumonia caused by amylase effusion, which can occur when pancreatic enzymes pass from the peritoneal cavity into the pleural cavity via the lymph channels across the diaphragm. The risk for acute respiratory distress syndrome (ARDS) also exists. Support for this answer can be obtained from the most current literature on the management of pancreatitis and complications related to the condition. Current evidence related to nursing management of pancreatitis may be retrieved from nursing specialty organizations such as the American Association of Critical Care Nurses, particularly if the patient experiences sepsis or hypovolemic shock from hemorrhage.

    2. What laboratory findings would you expect him to have? Why?

    Expected laboratory findings that indicate pancreatic cell damage include an increased serum amylase, elevated serum lipase, elevated serum trypsin, and elevated serum elastase. Elevated serum glucose is caused by impaired carbohydrate metabolism and decreased insulin release. Decreased serum calcium and magnesium levels occur when calcium combines with fatty acids and causes necrosis along with elevated leukocytes that indicate an inflammatory response.

    3. With whom should you collaborate to meet the desired outcomes for his care?

    Collaboration with a registered dietitian is important related to the patient’s dietary intake and requirements. Case management involvement may assist in placing the patient into rehabilitation when he is ready. Family and social support groups can also help. Respiratory therapy can assist in monitoring the patient for potential ARDS. Physical therapy can improve activity intolerance related to generalized weakness. The medical staff, patient, and significant others will also be involved in the management, decision making, and care of this patient while he is in the hospital and after discharge.

    4. What community support and health teaching is he going to require when he is discharged?

    The patient will need home care after discharge because of physical weakness from the acute episode. This can be arranged through a case manager or social worker. The patient will need to be educated on the disease process and its potential to become a chronic problem. Diet and nutrition and pain management should also be discussed. Information about support groups for the patient and family, such as Alcoholics Anonymous (AA), should be provided.
  5. (62) The nurse is attempting to position the client having an acute attack of pancreatitis in the most comfortable position possible. In which position will the nurse place this client?

    A. Supine, with a pillow supporting the abdomen
    B. Up in a chair between frequent periods of ambulation
    C. High Fowler's position, with pillows used as needed
    D. Side-lying position, with knees drawn up to the chest
    D. Side-lying position, with knees drawn up to the chest

    The side-lying position with the knees drawn up has been found to relieve abdominal discomfort related to acute pancreatitis.
    (this multiple choice question has been scrambled)
  6. (62)The nurse suspects that which client is at highest risk for developing gallstones?

    A. Thin female who has recently given birth
    B. Thin male with a history of coronary artery bypass grafting
    C. Obese female on hormone replacement therapy
    D. Obese male with a history of chronic obstructive pulmonary disease
    C. Obese female on hormone replacement therapy

    Women
    Aging
    Am Indian, Mex Am, Cauc
    Obesity
    Rapid weight loss or prolonged fasting
    Inc serum cholesterol
    Women on hormone replacement therapy or older birth control pills
    (this multiple choice question has been scrambled)
  7. (62) The nurse is teaching the client with gallbladder disease about diet modification. Which meal will the nurse suggest to the client?
    Avoid fatty foods (steaks, fried chicken, sausage) and cholesterol (eggs)
  8. (62) The client has developed acute pancreatitis after also developing gallstones. Which is the highest priority instruction for this client to avoid further attacks of pancreatitis?

    A. "If you have a gallbladder attack and pain does not resolve within a few days, call your doctor."
    B. "You'll need to drastically modify your alcohol intake."
    C. "See your physician immediately when experiencing symptoms of a gallbladder attack."
    D. "You may need a surgical consult for removal of your gallbladder."
    C. "See your physician immediately when experiencing symptoms of a gallbladder attack."

    Incorrect: A diagnostic statement like this must come from the physician. Also, the client may not require removal of the gallbladder.

    Correct: In this case, the client's pancreatitis was likely triggered by the development of gallstones.

    Incorrect: The client must see the physician promptly when experiencing gallbladder disease and should not wait.

    Incorrect: In this case, the client's acute pancreatitis is likely related to gallstones, not to alcohol consumption.
    (this multiple choice question has been scrambled)
  9. (62) The client diagnosed with acalculous cholecystitis asks the nurse how the gallbladder inflammation developed when there is no history of gallstones. What is the nurse's best response?

    A. "This may be an indication that you are developing sepsis."
    B. "The gallstones are present but have become fibrotic and contracted."
    C. "This type of gallbladder inflammation is associated with hypovolemia."
    D. "This may be an indication of pancreatic disease."
    C. "This type of gallbladder inflammation is associated with hypovolemia."

    Incorrect: Although this type of gallbladder inflammation is associated with sepsis, it is not an indicator that sepsis is developing.

    Incorrect: Fibrotic and contracted gallstones are associated with chronic cholecystitis.

    Correct: This type of gallbladder inflammation is associated with:
    Hypovolemia
    Sepsis
    Severe taruma or burns
    Long-term parental nutrition
    Multi-system organ failure
    Major surgery

    Incorrect: The presence of acalculous cholecystitis is not an indicator that pancreatic disease has developed.
    (this multiple choice question has been scrambled)
  10. (62) Which diagnostic results lead the nurse to suspect that a client may have gallbladder disease?

    A. Increased white blood cell (WBC) count, visualization of calcified gallstones, edema of the gallbladder wall
    B. Decreased WBC count, visualization of calcified gallstones, increased alkaline phosphatase
    C. Decreased WBC count, visualization of noncalcified gallstones, increased alkaline phosphatase
    D. Increased WBC count, visualization of noncalcified gallstones, edema of the gallbladder wall
    A. Increased white blood cell (WBC) count, visualization of calcified gallstones, edema of the gallbladder wall

    Correct: An increased WBC count is evidence of inflammation. Only calcified gallstones will be visualized on abdominal x-ray.

    Incorrect: The WBC count will be elevated, not decreased. Only calcified gallstones will be visualized on abdominal x-ray. Alkaline phosphatase will be elevated if liver function is abnormal. This is not common in gallbladder disease.

    Incorrect: An increased WBC count is evidence of inflammation. Noncalcified gallstones cannot be visualized by abdominal x-ray.

    Incorrect: The WBC count will be increased, not decreased. Noncalcified gallstones cannot be visualized. Alkaline phosphatase will be elevated if liver function is abnormal. This is not common in gallbladder disease.
    (this multiple choice question has been scrambled)
  11. (62) The nurse suspects that a client may have acute pancreatitis as evidenced by which group of laboratory results?

    A. Elevated lipase, elevated white blood cell count, elevated glucose
    B. Deceased calcium, elevated amylase, decreased magnesium
    C. Elevated bilirubin, elevated alkaline phosphatase
    D. Decreased blood urea nitrogen (BUN), elevated calcium, elevated magnesium
    A. Elevated lipase, elevated white blood cell count, elevated glucose

    Incorrect: Many pancreatic and nonpancreatic disorders can cause increased serum amylase levels.

    Incorrect: Bilirubin and alkaline phosphatase levels will be increased only if pancreatitis is accompanied by biliary dysfunction.

    Correct: Elevated lipase is more specific to a diagnosis of acute pancreatitis.

    Incorrect: Usually, calcium and magnesium will be increased and BUN increased, not decreased, in acute pancreatitis.
    (this multiple choice question has been scrambled)
  12. (62) The nurse expects that which client will be discharged to the home environment first?

    A. Older obese adult who has had a laparoscopic cholecystectomy
    B. Middle-aged thin adult who has had a laparoscopic cholecystectomy
    C. Older obese adult with chronic obstructive pulmonary disease (COPD) who has had a traditional cholecystectomy
    D. Middle-aged thin adult with a heart murmur who has had a traditional cholecystectomy
    B. Middle-aged thin adult who has had a laparoscopic cholecystectomy

    Incorrect: Although this client will have a faster discharge time than one with a traditional cholecystectomy, the client's obesity and age probably will cause a longer stay.

    Correct: The combination of client age, a thin frame, and the type of procedure performed (laparoscopic cholecystectomy) will cause the client to be discharged first.

    Incorrect: Whenever the client has a traditional cholecystectomy, the recovery time will be longer.

    Incorrect: Whenever the client has a traditional cholecystectomy, the recovery time will be longer. The client's history of COPD will also contribute to more lengthy recovery because of associated breathing problems.
    (this multiple choice question has been scrambled)
  13. (62) The nurse is caring for a client, recently diagnosed with type 1 diabetes mellitus, who has had an episode of acute pancreatitis. The client asks the nurse how he developed diabetes when the disease does not run in the family. What is the nurse's best response?

    A. "Type 1 diabetes can occur when the pancreas is destroyed by disease."
    B. "Do you use alcohol on a frequent basis?"
    C. "The diabetes could be related to your obesity."
    D. "What has your doctor told you about your disease?"
    A. "Type 1 diabetes can occur when the pancreas is destroyed by disease."

    Type 1, juvenile, insulin dependent
    Type 2, adult onset, obesity related
    (this multiple choice question has been scrambled)
  14. (62) Which set of assessment findings indicates to the nurse that the client may have acute pancreatitis?

    A. Presence of jaundice, pain worsening when lying supine
    B. Presence of jaundice, pain worsening when sitting up
    C. Absence of jaundice, pain in right abdominal quadrant
    D. Absence of jaundice, pain of gradual onset
    A. Presence of jaundice, pain worsening when lying supine

    Incorrect: Pain associated with acute pancreatitis usually has an abrupt onset, and jaundice is present.

    Incorrect: Pain associated with pancreatitis is usually located in the mid-epigastric or upper left quadrant, and jaundice is present.

    Incorrect: Pain associated with pancreatitis usually lessens with sitting up.

    Correct: Pain that worsens when lying supine and the presence of jaundice are the only assessment findings indicative of acute pancreatitis.
    (this multiple choice question has been scrambled)
  15. (62) The client is experiencing an attack of acute pancreatitis. Which nursing intervention is the highest priority for this client?

    A. Measure intake and output (I&O) every shift.
    B. Administer opioid analgesic medication.
    C. Assist the client to assume a position of comfort.
    D. Do not administer food or fluids by mouth.
    B. Administer opioid analgesic medication.

    Incorrect: Although this is an important intervention, measurement of I&O is not the highest priority for this client.

    Incorrect: Although the client should not receive any food or fluids by mouth, it is not the highest priority intervention for this client.

    Correct: For the client with acute pancreatitis, pain relief is the highest priority.

    Incorrect: Although it will be important to help the client lie comfortably, it is not the highest priority.
    (this multiple choice question has been scrambled)
  16. (62) The client has been placed on enzyme replacement for treatment of chronic pancreatitis. In teaching the client about this therapy, the nurse advises the client not to mix enzyme preparations with foods containing which element?

    A. High fiber
    B. High fat
    C. Carbohydrates
    D. Protein
    D. Protein

    Enzyme preparations (pancrelipase) should not be mixed with foods containing protein because the enzymes will dissolve the food into a watery substance.
    (this multiple choice question has been scrambled)
  17. (62) The client has undergone the Whipple procedure (radical pancreaticoduodenectomy) for pancreatic cancer. Which precautionary measures will the nurse implement to prevent potential complications? Select all that apply.

    A. Check blood glucose often.
    B. Check bowel sounds and stools.
    C. Ensure that drainage color is clear.
    D. Monitor mental status.
    E. Place the client in the supine position.
    A, B, D

    Correct: Glucose should be checked often to monitor for diabetes mellitus.

    Correct: Bowels sounds and stools should be checked to monitor for bowel obstruction.

    Correct: A change in mental status or level of consciousness could be indicative of hemorrhage.

    Incorrect: Clear, colorless, bile-tinged drainage or frank blood with increased output may indicate disruption or leakage of a site of anastomosis.

    Incorrect: The client should be placed in semi-Fowler's position to reduce tension on the suture line and the anastomosis site and to optimize lung expansion.
  18. (62) After receiving change-of-shift report on these clients, which client will the nurse plan to assess first?

    A. Middle-aged client who has an elevated temperature after undergoing endoscopic retrograde cholangiopancreatography (ERCP)
    B. Older adult client who is receiving total parenteral nutrition after a Whipple procedure and has a glucose level of 235 mg/dL
    C. Young adult client with acute pancreatitis who is dyspneic and has a respiratory rate of 34 to 38 breaths/min
    D. Adult client admitted with cholecystitis who is experiencing severe right upper quadrant abdominal pain
    C. Young adult client with acute pancreatitis who is dyspneic and has a respiratory rate of 34 to 38 breaths/min

    Correct: Acute respiratory distress syndrome is a possible complication of acute pancreatitis. The dyspneic client is at greatest risk for rapid deterioration and requires immediate assessment and intervention.

    Incorrect: This client will require further assessment and intervention, but the client's severe pain (from  cholecystitis who is experiencing severe right upper quadrant abdominal pain) is not a medical emergency requiring the nurse's immediate attention.

    Incorrect: This client will require further assessment and intervention, but the client's elevated temperature is not a medical emergency requiring the nurse's immediate attention.

    Incorrect: The client's glucose level will require intervention but is not a medical emergency requiring the nurse's immediate attention.
    (this multiple choice question has been scrambled)
  19. (62) The nurse is preparing to instruct a client with chronic pancreatitis who is to begin taking pancrelipase (Cotazym). Which instruction will the nurse include when teaching the client about this medication?

    A. Take pancrelipase before meals.
    B. Wipe your lips after taking pancrelipase.
    C. Chew tablets before swallowing.
    D. Administer pancrelipase before taking an antacid.
    B. Wipe your lips after taking pancrelipase.

    Incorrect: Pancrelipase (Cotazym) is a pancreatic enzyme that should be administered after antacids or H2 blockers are taken.

    Incorrect: Pancrelipase (Cotazym) is a pancreatic enzyme that should not be chewed to minimize oral irritation and allow the drug to be released more slowly.

    Incorrect: Pancrelipase (Cotazym) is a pancreatic enzyme that should be taken with meals and snacks and followed with a glass of water.

    Correct: Pancrelipase (Cotazym) is a pancreatic enzyme used for enzyme replacement for clients with chronic pancreatitis. To avoid skin irritation and breakdown from residual enzymes, the lips should be wiped.  
    (this multiple choice question has been scrambled)

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