Each question is 2 part = total 5 points Correct answer 2.5 points Rational 2.5
ID: 243869 • Letter: E
Question
Each question is 2 part = total 5 points
Correct answer 2.5 points
Rational 2.5 points
Tommy, 52 year old Hispanic, is brought into the emergency room by his wife complaining of severe abdominal and back pain. He has been vomiting for the last 24 hours. Tommy was diagnosed with chronic pancreatitis 22 months ago with frequent visits and three admissions for acute exacerbation of pancreatitis. He owns his own company, which is highly stressful, and he has two teenagers.
The nurse will perform a history and physical on Tommy. Which question should the nurse ask Tommy regarding the admitting diagnosis of acute pancreatitis?
“Do you currently, or have you ever, smoked cigarettes?”
“What medications have you taken in the last 24 hours?”
“How often do you drink alcohol, and when was your last drink?”
“Have you had any weight loss or gain in the last 6 months?”
Which lab result indicates that Tommy is experiencing acute pancreatitis?
Hemoglobin 12.9 g/dl and hematocrit 42%
White blood cell count of 10,000/mm
Blood alcohol level of 1.0 mg
Amylase of 982 U/L and Lipase of 400 U/L
While in the emergency room, the starts a peripheral IV site to his right forearm. The nurse hangs D5 ½ NS at 125 mL/hr . Tommy complains of severe abdominal pain rated “9” on a 1-10 numerical pain scale. Tommy’s abdomen is soft and non-tender and bowel sounds in all 4 quadrants are present on auscultation. Which medication should the nurse expect to administer to relieve Tommy’s pain?
Ondansetron 0.15 mg IV push dilutes and administered over 15 minutes
Morphine 5m IV push administered diluted over 5 minutes
Ranitidine IVPB administered over 30 minutes
Promethazine 25 mg deep intramuscular injection
The nurse monitors Tommy who received an opioid analgesia fo adverse effects of the mediation. Which of the following effects should the nurse not anticipate?
Bradypnea
Orthostatic hypotension
Nausea
Diarrhea
The nurse is completing the admission assessment of Tommy admitted with acute pancreatitis. Which of the following is an expected finding?
Pain relieved with defecation
Epigastric pain radiating to the left shoulder
Report of pain being worse when sitting upright
Pain in right upper quadrant radiating to right shoulder
Which of following findings if discovered during the admission assessment of Tommy is a priority to be reported to the provider?
Client report of severe pain radiating to the back that is rated an “8”
Serum amylase levels three times greater than the expected value
Hand spasms present when blood pressure is checked
History of cholelithiasis
A nurse is reviewing the health record of a client who has pancreatitis. The physical exam report by the health care provider indicates the presence of Cullen’s sign. Which of the following as an appropriate action by the nurse to identify this finding?
Inspect the skin around the umbilicus
Palpate the client’s right lower quadrant
Tap lightly at the costovertebral margin on the client’s back
Auscultate the area below the client’s scapula
What diet should the nurse expect the healthcare provider to order for Tommy?
Regular diet
Low fat diet
Clear liquid diet
NPO
An appropriate nursing diagnosis for Tommy with pancreatitis is “imbalanced nutrition: less than body requirements.” All of the following are possible risk factors for this nursing diagnosis except for:
Altered ability to digest nutrients
GI distress (nausea and/or vomiting)
Alteration in clotting process
Prescribed dietary restrictions
The following orders below are ordered for Tommy. Which intervention should the nurse implement prior to transferring Tommy to the floor?
Obtain consent for the endoscopic retrograde cholangiopancreatography (ERCP)
Attach an urometer to a drainage bag and insert a 16 guage Foley catheter
Call report to the receiving nurse prior to transferring the patient to the medical surgical unit
Insert a nasogastric tube and connect to low, intermittent suction
Tommy is stable and on the medical surgical unit. The nasogastric tube is draining green bile, and Tommy reports his pain is a “4”” on the 0-10 pain scale. Which intervention regarding positioning should the nurse implement to help alleviate Tommy’s pain?
Ensure that Tommy remains in a supine position
Encourage side lying with legs drawn to chest
Place 6 inch blocks under the foot of the bed
No specific position will help Tommy’s pain
A couple of days after admission, Tommy is unable to tolerate foods or fluids by mouth. The healthcare provider orders total parenteral nutrition (TPN). Which intervention should the nurse implement prior to administering TPN?
Assess the patency of the nasogastric tube
Assist the healthcare provider with a subclavian line insertion
Restart Tommy’s IV with an 18 gauge angiocath
Consult with a registered dietician about the formula
Which independent nursing action regarding Tommy’s nutritional status should the nurse include in the plan of care?
Monitor his abdominal girth
Offer high-protein snacks frequently
Change the TPN IV tubing every 48 hours
Obtain and record a daily weight
The nurse is preparing to hang Tommy’s second bag of TPN after the 1st one has finished infusing at 75 mL/hr. The TPN bag #2 has not been delivered from the pharmacy. The pharmacist said they are working on it. Which action should the nurse take?
Administer D10W via the infusion pump at 75 mL/hr
Notify the charge nurse that the TPN bag #2 is not on the unit
Instruct the pharmacy to bring the bag to the floor immediately
Hang D5W via the infusion pump at a keep-vein-open rate
The nurse is planning care for Tommy who is now receiving TPN. Which of the following intervention is not applicable in the plan of care?
Administer ordered medications through a secondary port on the TPN IV tubing.
Change the TPN IV tubing every 24 hours
Obtain capillary blood glucose four times a day as ordered
Monitor vital signs 2 – 3 times during the 12 hour shift
The nurse noticed that it has been 24 hours since the current bag of TPN solution was hung, and 300 mL remains to infuse. Which of the following is the appropriate action for the nurse to take?
Infuse the remaining solution at the current rate and then hang a new bag
Increase the infusion rate so the remaining solution is administered within the hour and hand a new bag
Remove the current bag and hang a new bag
Remove the current bag and hang a bag of Lactated Ringer’s solution
Which intervention has the highest priority when preparing Tommy’s discharge?
Discuss the need to avoid spicy foods
Refer Tommy to Alcoholics Anonymous (AA)
Instruct Tommy to eat a high carbohydrate, low-fat diet
Explain the importance of alcohol abstinence
Approximately 3 weeks post discharge, Tommy is scheduled for another ERCP. After receiving further explanation by the healthcare provider, he signed the consent form and the nurse completes the pre-procedure assessment. Which question should the nurse ask Tommy prior to the ERCP?
When was the last time you had anything to eat or drink?
When was the last time you had a bowel movement?
Have you consumed any alcohol in the last 48 hours?
Do you have any difficulty swallowing or chewing?
Tommy undergoes the ERCP without any complications. What intervention has the highest priority when caring for him after the procedure?
Monitor the client’s IV fluids
Check the client’s abdomen for pain and tenderness
Assess the clients pulse and blood pressure
Evaluate the client’s hemoglobin and hematocrit
Tommy has a follow-up visit after the ERCP. He informs the nurse that he doesn’t drink much alcohol, and is trying to cut down on his smoking. He adds that he has quit drinking tea and cola, but he has to have his morning coffee. The also tell the nurse that his stools look fatty, appear bubbly and frothy, float on top of the water, and are extremely malodorous. How should the nurse respond?
“We need to get a stool specimen and send it to the lab.”
“This is common in persons with chronic pancreatitis.”
“Have you been eating any fatty foods in the last few days?’
“This happens when you drink too much alcohol.”
Explanation / Answer
1. The nurse must ask the following question to the patient:
2. The following lab investigation shows acute pancreatitis:
3. Nurse should administer Morphine 5m IV push administered diluted over 5 minutes.
4. Opioid analgesia may cause nausea in patient so nurse should assess the patient condition if severe nausea present.
5. The expected finding will be: Pain in right upper quadrant radiating to right shoulder, as severe pain is the main symptom of the acute pancreatitis.
6. Serum amylase levels three times greater than the expected value, this is the main priority value to be discussed with the health care provider.
7. To determine the Cullen's sign nurse should inspect the area around the umblicus because in cullen's sign there is bruising occur in subcutaneous fatty tissues around the umblicus.
8. Low fat diet should be prescribed to the patient, because more fat in diet leads to inflammation and pain thus delay in the recovering process.
9. Acute Pancreatitis doesn't cause any ALTERATION IN CLOTTING PROCESS.
10. Obtain consent for the endoscopic retrograde cholangiopancreatography (ERCP), this is the main priority intervention before transferring patient to floor, because without consent no treatment can be given to patient.
11. To reduce the pain nurse should Encourage side lying position with legs drawn to chest, it helps to reduce the pain.
12. The nurse should Consult with a registered dietician about the formula, when the Tommy is unable to tolerate food and fluids, the dietician may provide another alternative measure.
13. Tommy's weight should be obtained and recorded daily, as in acute pancreatitis client's weight starts reducing.
14. The nurse should Notify the charge nurse that the TPN bag #2 is not on the unit, to prevent communication barrier in patient care.
15.Administer ordered medications through a secondary port on the TPN IV tubing, this is not applicable in plan care.
16. Increase the infusion rate so the remaining solution is administered within the hour and hang a new bag, to maintain the medication order and to maintain the nutritional status of the patient.
17. The main important priority discussion during discharge process is to teach the client about the importance of alcohol abstinence, as alcohol consumption is the main cause of the acute pancreatitis.
18. The nurse should ask the following question:
19. After the procedure the nurse should check the client for pain and tenderness in abdomen, as the procedure may cause pain to patient.
20. The nurse should respond that, “We need to get a stool specimen and send it to the lab.", to diagnose accurately the cause behind the symptoms.
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