ATI LPN
Test Bank for Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care 10th Edition
Chapter 59 : Care of Patients with Problems of the Biliary System and Pancreas Questions
Question 1 of 5
A nurse assesses a client who is recovering from an open Whipple procedure. Which action should the nurse perform first?
Correct Answer: A
Rationale: Using the ABCs, airway and oxygenation status should always be assessed first, so checking the endotracheal tube is the first action. Next, the nurse should start the IV line (circulation). After that, the Foley catheter can be inserted, and the nasogastric tube can be set.
Question 2 of 5
A nurse cares for a client with end-stage pancreatic cancer. The client asks, 'Why is this happening to me?' How should the nurse respond?
Correct Answer: A
Rationale: The client is not asking the nurse to actually explain why the cancer has occurred. The client may be experiencing feelings of confusion, frustration, distress, and grief related to the diagnosis. The nurse should validate that there is no easy or straightforward answer as to why the client has cancer. Other options do not address the client's emotions or current concerns.
Question 3 of 5
A nurse assesses a client who has cholecystitis. Which clinical manifestation indicates that the condition is chronic rather than acute?
Correct Answer: C
Rationale: Hematuria, clay-colored stools, and dark urine are more commonly seen with chronic cholecystitis. The other symptoms are seen equally with both chronic and acute cholecystitis.
Question 4 of 5
A nurse cares for a client who is prescribed patient-controlled analgesia (PCA) after a cholecystectomy. The client states, 'When I wake up, I am in pain.' Which action should the nurse take?
Correct Answer: B
Rationale: The nurse should encourage the client to use the PCA pump prior to napping and upon awakening. Administering additional intravenous morphine while the client sleeps places the client at risk for respiratory depression. Only the client should push the pain button on a PCA pump.
Question 5 of 5
A nurse cares for a client with acute pancreatitis. The client states, 'I am hungry.' How should the nurse reply?
Correct Answer: C
Rationale: Paralytic ileus is a common complication of acute pancreatitis. The client should not eat until this has resolved. Bowel sounds and decreased pain are not reliable indicators of peristalsis. Instead, the nurse should assess for passage of flatus or bowel movement.