SOLUTIONS
A client had an open traditional Whipple procedure this
morning. For what priority complication would the nurse assess?
a. Urinary tract infection
b. Chronic kidney disease
c. Heart failure
d. Fluid and electrolyte imbalances Correct Answer ANS: D
Due to the length and complexity of this type of surgery, the
client is at risk for fluid and electrolyte imbalances. The nurse
would assess for signs and symptoms of these imbalances so
they can be managed early to prevent potentially life-threatening
complications.
A client has a 4,000 mL removed via paracentesis. When the
nurse weighs the client after the procedure, how many kilograms
is an expected weight loss? Record you answer in whole
numbers. Correct Answer 4 kg
A client has an external percutaneous transhepatic biliary
catheter inserted for a biliary obstruction. What health teaching
about catheter care would the nurse provide for the client?
a. "Cap the catheter drain at night to prevent leakage and skin
damage."
b. "Position the drainage bag lower than the catheter insertion
site."
c. "Irrigate the catheter with an ounce of saline every night."
d. "Pierce a hole in the top of the drainage bag to get rid of
odors." Correct Answer ANS: B An external temporary or
permanent catheter drains bile by gravity into a bag that collects
,bile. Therefore, the drainage bag should be lower that the
catheter insertion site. The catheter should not be capped or
irrigated, and no holes should be made in the bag to prevent bile
from having contact with the skin.
A client has had an exacerbation of ulcerative colitis with
cramping and diarrhea persisting longer than 1 week. The nurse
should assess the client for which complication?
a. Heart failure
b. Deep vein thrombosis
c. Hypokalemia
d. Hypocalcemia Correct Answer ANS: C
A client has had an exacerbation of ulcerative colitis with
cramping and diarrhea persisting longer than 1 week. The nurse
should assess the client for which complication?
a. Heart failure
b. Deep vein thrombosis
c. Hypokalemia
d. Hypocalcemia Correct Answer C
A client is admitted with a diagnosis of possible strangulated
inguinal hernia. For which complication would the nurse
monitor?
a. Paralytic ileus
b. Bowel volvulus
c. Sepsis
d. Colitis Correct Answer ANS: C The client who has a
strangulated inguinal hernia would likely develop bowel
necrosis which can lead to sepsis. The nurse would observe for
early signs and symptoms of sepsis such as fever, tachypnea,
,and tachycardia. If the client's condition is not promptly
managed, bowel perforation, septic shock, and death can result.
A client is admitted with acute pancreatitis. What priority
problem would the nurse expect the client to report?
a. Nausea and vomiting
b. Severe boring abdominal pain
c. Jaundice and itching
d. Elevated temperature Correct Answer ANS: B The client
who has acute pancreatitis reports severe boring abdominal pain
that is often rated by clients as a 10+ on a 0-10 pain scale.
Nausea, vomiting, and fever may also occur, but that is not the
client's priority for care.
A client is admitted with inflammatory bowel syndrome
(Crohn's disease). When planning care for the health care team,
which would be included? (Select all that apply.)
a. Lactulose therapy
b. High fiber diet
c. High protein milkshakes
d. Corticosteroid therapy
e. Antidiarrheal medications Correct Answer D, E
A client is preparing to have a fecal occult blood test (FOBT).
What health teaching would the nurse include prior to the test?
a. "This test will determine whether you have colorectal cancer."
b. "You need to avoid red meat and NSAIDs for 48 hours before
the test."
c. "You don't need to have this test because you can have a
virtual colonoscopy."
, d. "This test can determine your genetic risk for developing
colorectal cancer." Correct Answer ANS: B The FOBT is a
screening test that is sometimes used to assess for microscopic
lower GI bleeding. To help prevent false positive results, the
client needs to avoid red meat, Vitamin C, and NSAIDs. The test
is not diagnostic nor does it determine a client's genetic risk for
colorectal cancer.
A client is scheduled for a hepatobiliary iminodiacetic acid
(HIDA) scan. What would the nurse include in client teaching
about this diagnostic test?
a. "You'll have to drink a contrast medium right before the test."
b. "You'll need to do a bowel prep the nursing before the test."
c. "You'll be able to drink liquids up until the test begins."
d. "You'll have a large camera close to you during the test."
Correct Answer ANS: D Clients having a HIDA scan are NPO
and receive an injectable nuclear medicine contrast. No bowel
preparation is required. A large camera is close to the client for
most of the test which can be a problem for clients who are
claustrophobic.
A client who has ulcerative colitis has persistent diarrhea and
has lost 12 lb since the exacerbation of the disease. Which
approach will be most effective in helping the client meet
nutritional needs?
a. Continuous enteral feedings
b. Following a high calorie, high protein diet
c. Total parenteral nutrition
d. Earing six small meals a day Correct Answer ANS: C