Questions with Verified Answers and Detailed Rationales
Which intervention will the nurse implement for a client hospitalized with acute
pancreatisis? - correct answer - Administer analgesics
- Teach relaxation exercises
- monitor cardiac rate & rhythm
- provide antiemetics
Rationale:
Analgesics, histamine-receptor antagonists, and proton pump inhibitors may be
administered to decrease gastrointestinal activity and the secretion of pancreatic
enzymes. Relaxation will decrease the metabolic rate, which will decrease
gastrointestinal activity, including the secretion of pancreatic enzymes. Monitoring
cardiac rate and rhythm is necessary to assess for hypokalemia and fluid volume
changes. Antiemetics will be administered to help reduce nausea and vomiting. The
client would be kept nothing by mouth to decrease gastrointestinal activity and the
secretion of pancreatic enzymes and therefore would not have a high-fat diet order.
Once PO nutrition is resumed the diet would include high-carbohydrate and protein, but
low-fat. Walking increases the metabolic rate, which will increase gastrointestinal
activity, including the secretion of pancreatic enzymes. Hypocalcemia, not
hypercalcemia, occurs because of calcium and fatty acids combining during fat
necrosis. The client with acute pancreatitis is at risk for inadequate nutrition and will be
weighed daily.
Which food selection by a client with celiac disease indicates the nurse's dietary
teaching was successful? SATA
Green beans
Baked potato
Egg noodles
Turkey sandwich
Baked salmon
Whole-wheat cereal
, Fried eggs
Whole milk - correct answer Green beans, baked potato, baked salmon, fried eggs,
whole milk
Rationale: Noodles, bread in the turkey sandwich, and whole-wheat cereal are high in
gluten, and clients on gluten-free diets should avoid these products. Celiac clients are to
avoid gluten found in wheat, oats, and barley.
Which nursing action is appropriate when providing care to a hospitalized infant who is
diagnosed with failure to thrive (FTT) due to inadequate caloric intake? SATA
Consulting with social work
Monitoring for sensitivity to cow's milk
Assessing juice consumption
Teaching the parents how to prepare formula
Evaluating for severe allergies
Examining the EHR for diagnosis of cystic fibrosis
Analyzing eating patterns and diet for signs of celiac disease
Reviewing laboratory data related to thyroid function - correct answer - Consulting with
social work
- Assessing juice consumption
- Teaching the parents how to prepare formula
Rationale: Poor infant growth with a diagnosis of FTT due to inadequate caloric intake
requires the nurse to consult with social work to determine if the family is living in
poverty; assess the infant's juice consumption (too much juice and not enough formula
often causes inadequate caloric intake); and teach the parents how to properly prepare
formula (too much water decreases the amount of calories). A sensitivity to cow's milk or
other severe allergies would cause FTT due to inadequate absorption, not inadequate
caloric intake. Additional causes of FTT associated with inadequate absorption include
medical conditions such as celiac disease and cystic fibrosis. Some diseases can
contribute to FTT through an elevated metabolism including cystic fibrosis and
hyperthyroidism. If hyperthyroidism was suspected laboratory data would be monitored.