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  1. A patient who was admitted to the hospital with hyperglycemia and newly diagnosed diabetes
    mellitus is scheduled for discharge the second day after admission. When implementing patient
    teaching, what is the priority action forthe nurse?
    a. Instruct about the increased risk for cardiovascular disease.
    b. Provide detailed information about dietary control of glucose.
    c. Teach glucose self-monitoring and medication administration.
    d. Give information about the effects of exercise on glucose control.
    ANS: C
    When time is limited, the nurse should focus on the priorities of teaching. In this situation, the
    patient should know how to test blood glucose and administer medications to control glucose
    levels. The patient will need further teaching about the role of diet, exercise, various
    medications, and the many potential complications of diabetes, but these topics can be addressed
    through planning for appropriate referrals.
  2. A 75-year-old patient is admitted for pancreatitis. Which tool would be the most appropriate
    for the nurse to use during the admission assessment?
    a. Drug Abuse Screening Test (DAST-10)
    b. Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar)
    c. Screening Test-Geriatric Version (SMAST-G)
    d. Mini-Mental State Examination
    ANS: C
    Because the abuse of alcohol is a common factor associated with the development of
    pancreatitis, the first assessment step is to screen for alcohol use using a validated screening
    questionnaire. The SMAST-G is a short-form alcoholism screening instrument tailored
    specifically to the needs of the older adult. If the patient scores positively on the SMAST-G, then
    the CIWA-Ar would be a useful tool for determining treatment. The DAST-10 provides more
    general information regarding substance use. The Mini-Mental State Examination is used to
    screen for cognitive impairment.
  3. The sister of a patient diagnosed with BRCA gene–related breast cancer asks the nurse, “Do
    you think I should be tested for the gene?” Which response by the nurse is most appropriate?
    a. “In most cases, breast cancer is not caused by the BRCA gene.”
    b. “It depends on how you will feel if the test is positive for the BRCA gene.”
    c. “There are many things to consider before deciding to have genetic testing.”
    d. “You should decide first whether you are willing to have a bilateral mastectomy.”
    ANS: C
    Although presymptomatic testing for genetic disorders allows patients to take action (such as
    mastectomy) to prevent the development of some genetically caused disorders, patients also need
    to consider that test results in their medical record may affect insurance, employability, etc.
    Telling a patient that a decision about mastectomy should be made before testing implies that the
    nurse has made a judgment about what the patient should do if the test is positive. Although the
    patient may need to think about her reaction if the test is positive, other issues (e.g., insurance)
    also should be considered. Although most breast cancers are not related to BRCA gene mutations,
    the patient with a BRCA gene mutation has a markedly increased risk for breast cancer.
  4. The nurse in the outpatient clinic has obtained health histories for these new patients. Which
    patient may need referral for genetic testing?
    a. 35-year-old patient whose maternal grandparents died after strokes at ages 90 and 96
    b. 18-year-old patient with a positive pregnancy test whose first child has cerebral palsy
    c. 34-year-old patient who has a sibling with newly diagnosed polycystic kidney disease
    d. 50-year-old patient with a history of cigarette smoking who is complaining of dyspnea
    ANS: C
    The adult form of polycystic kidney disease is an autosomal dominant disorder and frequently it is
    asymptomatic until the patient is older. Presymptomatic testing will give the patient information that
    will be useful in guiding lifestyle and childbearing choices. The other patients do not have any
    indication of genetic disorders or need for genetic testing.
  5. An adolescent patient seeks care in the emergency department after sharing needles forheroin
    injection with a friend who has hepatitis B. To provide immediate protection from infection, what
    medication will the nurse administer?
    a. Corticosteroids
    b. Gamma globulin
    c. Hepatitis B vaccine
    d. Fresh frozen plasma
    ANS: B
    The patient should first receive antibodies for hepatitis B from injection of gamma globulin. The
    hepatitis B vaccination series should be started to provide active immunity. Fresh frozen plasma
    and corticosteroids will not be effective in preventing hepatitis B in the patient.
  6. A patient who is diagnosed with cervical cancer that is classified as Tis, N0, M0 asks the nurse
    what the letters and numbers mean. Which response by the nurse is most appropriate?
    a. “The cancer involves only the cervix.”
    b. “The cancer cells look almost like normal cells.”
    c. “Further testing is needed to determine the spread of the cancer.”
    d. “It is difficult to determine the original site of the cervical cancer.”
    ANS: A
    Cancer in situ indicates that the cancer is localized to the cervix and is not invasive at this time.
    Cell differentiation is not indicated by clinical staging. Because the cancer is in situ, the origin is
    the cervix. Further testing is not indicated given that the cancer has not spread.
  7. External-beam radiation is planned for a patient with cervical cancer. What instructions should the
    nurse give to the patient to prevent complications from the effects of the radiation?
    a. Test all stools for the presence of blood.
    b. Maintain a high-residue, high-fiber diet.
    c. Clean the perianal area carefully after every bowel movement.
    d. Inspect the mouth and throat daily for the appearance of thrush.
    ANS: C
    Radiation to the abdomen will affect organs in the radiation path, such as the bowel, and cause frequent
    diarrhea. Careful cleaning of this area will help decrease the risk for skin breakdown and infection.
    Stools are likely to have occult blood from the inflammation associated with radiation, so routine testing
    of stools for blood is not indicated. Radiation to the abdomen will not cause stomatitis. A low-residue
    diet is recommended to avoid irritation of the bowel when patients receive abdominal radiation.
  8. The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep
    respirations. Which action should the nurse take?
    a. Give the prescribed PRN lorazepam (Ativan).
    b. Start the prescribed PRN oxygen at 2 to 4 L/min.
    c. Administer the prescribed normal saline bolus and insulin.
    d. Encourage the patient to take deep, slow breaths with guided imagery.
    ANS: C
    The rapid, deep (Kussmaul) respirations indicate a metabolic acidosis and the need for correction of the
    acidosis with a saline bolus to prevent hypovolemia followed by insulin administration to allow glucose to
    reenter the cells. Oxygen therapy is not indicated because there is no indication that the increased
    respiratory rate is related to hypoxemia. The respiratory pattern is compensatory, and the patient will not
    be able to slow the respiratory rate. Lorazepam administration will slow the respiratory rate and increase
    the level of acidosis.
  9. The nurse is caring for a patient who has a calcium level of 12.1 mg/dL. Which nursing
    action should the nurse include on the care plan?
    a. Maintain the patient on bed rest.
    b. Auscultate lung sounds every 4 hours.
    c. Monitor for Trousseau’s and Chvostek’s signs.
    d. Encourage fluid intake up to 4000 mL every day.
    ANS: D
    To decrease the risk for renal calculi, the patient should have a fluid intake of 3000 to 4000 mL daily.
    Ambulation helps decrease the loss of calcium from bone and is encouraged in patients with
    hypercalcemia. Trousseau’s and Chvostek’s signs are monitored when there is a possibility of
    hypocalcemia. There is no indication that the patient needs frequent assessment of lung sounds, although
    these would be assessed every shift.
  10. A patient who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction and
    is complaining of anxiety and incisional pain. The patient’s respiratory rate is 32 breaths/minute and the
    arterial blood gases (ABGs) indicate respiratory alkalosis. Which action should the nurse take first?
    a. Discontinue the nasogastric suction.
    b. Give the patient the PRN IV morphine sulfate 4 mg.
    c. Notify the health care provider about the ABG results.
    d. Teach the patient how to take slow, deep breaths when anxious.
    ANS: B
    The patient’s respiratory alkalosis is caused by the increased respiratory rate associated with pain and
    anxiety. The nurse’s first action should be to medicate the patient for pain. Although the nasogastric
    suction may contribute to the alkalosis, it is not appropriate to discontinue the tube when the patient needs
    gastric suction. The health care provider may be notified about the ABGs but is likely to instruct the nurse
    to medicate for pain. The patient will not be able to take slow, deep breaths when experiencing pain.
  11. Which topic is most important for the nurse to discuss preoperatively with a patient who is scheduled
    for abdominal surgery for an open cholecystectomy?
    a. Care for the surgical incision
    b. Medications used during surgery
    c. Deep breathing and coughing techniques
    d. Oral antibiotic therapy after discharge home
    ANS: C
    Preoperative teaching, demonstration, and redemonstration of deep breathing and coughing are needed on
    patients having abdominal surgery to prevent postoperative atelectasis. Incisional care and the importance of
    completing antibiotics are better discussed after surgery, when the patient will be more likely to retain this
    information. The patient does not usually need information about medications that are used intraoperatively.
  12. The nurse is caring for a patient the first postoperative day following a laparotomy for a small bowel
    obstruction. The nurse notices new bright-red drainage about 5 cm in diameter on the dressing. Which
    action should the nurse take first?
    a. Reinforce the dressing.
    b. Apply an abdominal binder.
    c. Take the patient’s vital signs.
    d. Recheck the dressing in 1 hour for increased drainage.
    ANS: C
    New bright-red drainage may indicate hemorrhage, and the nurse should initially assess the patient’s vital
    signs for tachycardia and hypotension. The surgeon should then be notified of the drainage and the vital
    signs. The dressing may be changed or reinforced, based on the surgeon’s orders or institutional policy.
    The nurse should not wait an hour to recheck the dressing.
  13. Which prescribed medication should the nurse give first to a patient who has just been admitted to
    a hospital with acute angle-closure glaucoma?
    a. Morphine sulfate 4 mg IV
    b. Mannitol (Osmitrol) 100 mg IV
    c. Betaxolol (Betoptic) 1 drop in each eye
    d. Acetazolamide (Diamox) 250 mg orally
    ANS: B
    The most immediate concern for the patient is to lower intraocular pressure, which will occur most rapidly
    with IV administration of a hyperosmolar diuretic such as mannitol. The other medications are also
    appropriate for a patient with glaucoma but would not be the first medication administered.
  14. A patient’s capillary blood glucose level is 120 mg/dL 6 hours after the nurse initiated a parenteral
    nutrition (PN) infusion. The most appropriate actionby the nurse is to
    a. obtain a venous blood glucose specimen.
    b. slow the infusion rate of the PN infusion.
    c. Recheck the capillary blood glucose in 4 to 6 hours.
    d. notify the health care provider of the glucose level.
    ANS: C
    Mild hyperglycemia is expected during the first few days after PN is started and requires ongoing monitoring.
    Because the glucose elevation is small and expected, notification of the health care provider is not necessary.
    There is no need to obtain a venous specimen for comparison. Slowing the rate of the infusion is beyond the
    nurse’s scope of practice and will decrease the patient’s nutritional intake.
  15. A patient being admitted with an acute exacerbation of ulcerative colitis reports crampy abdominal
    pain and passing 15 or bloodier stools a day. The nurse will plan to
    a. administer IV metoclopramide (Reglan).
    b. Discontinue the patient’s oral food intake.
    c. administercobalamin (vitamin B12) injections.
    d. teach the patient about total colectomy surgery.
    ANS: B
    An initial therapy for an acute exacerbation of inflammatory bowel disease (IBD) is to rest the bowel by
    making the patient NPO. Metoclopramide increases peristalsis and will worsen symptoms. Cobalamin
    (vitamin B12) is absorbed in the ileum, which is not affected by ulcerative colitis. Although total colectomy
    is needed for some patients, there is no indication that this patient is a candidate.
  16. Which nursing action will the nurse include in the plan of care for a 35-year-old male patient admitted
    with an exacerbation of inflammatory bowel disease (IBD)?
    a. Restrict oral fluid intake.
    b. Monitor stools for blood.
    c. Ambulate four times daily.
    d. Increase dietary fiber intake.
    ANS: B
    Because anemia or hemorrhage may occur with IBD, stools should be assessed for the presence of blood.
    The other actions would not be appropriate for the patient with IBD. Because dietary fiber may increase
    gastrointestinal (GI) motility and exacerbate the diarrhea, severe fatigue is common with IBD
    exacerbations, and dehydration may occur.
  17. Which patient statement indicates that the nurse’s teaching about sulfasalazine (Azulfidine) for ulcerative
    colitis has been effective?
    a. “The medication will be tapered if I need surgery.”
    b. “I will need to use a sunscreen when I am outdoors.”
    c. “I will need to avoid contact with people who are sick.”
    d. “The medication will prevent infections that cause the diarrhea.”
    ANS: B
    Sulfasalazine may cause photosensitivity in some patients. It is not used to treat infections. Sulfasalazine
    does not reduce immune function. Unlike corticosteroids, tapering of sulfasalazine is not needed.
  18. A 22-year-old female patient with an exacerbation of ulcerative colitis is having 15 to 20 stools daily
    and has excoriated perianal skin. Which patient behavior indicates that teaching regarding maintenance
    of skin integrity has been effective?
    a. The patient uses incontinence briefs to contain loose stools.
    b. The patient asks for antidiarrheal medication after each stool.
    c. The patient uses witch hazel compresses to decrease irritation.
    d. The patient cleans the perianal area with soap after each stool.
    ANS: C
    Witch hazel compresses are suggested to reduce anal irritation and discomfort. Incontinence briefs may
    trap diarrhea and increase the incidence of skin breakdown. Antidiarrheal medications are not given 15
    to 20 times a day. The perianal area should be washed with plain water after each stool.
  19. Which diet choice by the patient with an acute exacerbation of inflammatory bowel disease (IBD)
    indicates a need for more teaching?
    a. Scrambled eggs
    b. White toast and jam
    c. Oatmeal with cream
    d. Pancakes with syrup
    ANS: C
    During acute exacerbations of IBD, the patient should avoid high-fiber foods such as whole grains.
    High-fat foods also may cause diarrhea in some patients. The other choices are low residue and would be
    appropriate for this patient.
  20. After a total proctocolectomy and permanent ileostomy, the patient tells the nurse, “I cannot manage
    all these changes. I don’t want to look at the stoma.” What is the best action by the nurse?
    a. Reassure the patient that ileostomy care will become easier.
    b. Ask the patient about the concerns with stoma management.
    c. Develop a detailed written lis t of ostomy care tasks for the patient.
    d. Postpone any teaching until the patient adjusts to the ileostomy.
    ANS: B
    Encouraging the patient to share concerns assists in helping the patient adjust to the body changes.
    Acknowledgment of the patient’s feelings and concerns is important rather than offering false reassurance.
    Because the patient indicates that the feelings about the ostomy are the reason for the difficulty with the many
    changes, development of a detailed ostomy care plan will not improve the patient’s ability to manage the
    ostomy. Although detailed ostomy teaching may be postponed, the nurse should offer teaching about some
    aspects of living with an ostomy.
  21. A 73-year-old patient with diverticulosis has a large bowel obstruction. The nurse will
    monitor for
    a. referred back pain.
    b. metabolic alkalosis.
    c. projectile vomiting.
    d. Abdominal distention.
    ANS: D
    Abdominal distention is seen in lower intestinal obstruction. Referred back pain is not a common clinical
    manifestation of intestinal obstruction. Metabolic alkalosis is common in high intestinal obstruction because
    of the loss of HCl acid from vomiting. Projectile vomiting is associated with higher intestinal obstruction.
  22. A 47-year-old female patient is transferred from the recovery room to a surgical unit after a
    transverse colostomy. The nurse observes the stoma to be deep pink with edema and a small
    amount of sanguineous drainage. The nurse should
    a. place ice packs around the stoma.
    b. notify the surgeon about the stoma.
    c. monitor the stoma every 30 minutes.
    d. Document stoma assessment findings.
    ANS: D
    The stoma appearance indicates good circulation to the stoma. There is no indication that surgical intervention
    is needed or that frequent stoma monitoring is required. Swelling of the stoma is normal for 2 to 3 weeks after
    surgery, and an ice pack is not needed.
  23. Which information will the nurse include in teaching a patient who had a proctocolectomy and
    ileostomy for ulcerative colitis?
    a. Restrict fluid intake to prevent constant liquid drainage from the stoma.
    b. Use care when eating high-fiber foods to avoid obstruction of the ileum.
    c. Irrigate the ileostomy daily to avoid having to wear a drainage appliance.
    d. Change the pouch every day to prevent leakage of contents onto the skin.
    ANS: B
    High-fiber foods are introduced gradually and should be well chewed to avoid obstruction of the ileostomy.
    Patients with ileostomies lose the absorption of water in the colon and need to take in increased amounts of
    fluid. The pouch should be drained frequently but is changed every 5 to 7 days. The drainage from an
    ileostomy is liquid and continuous, so control by irrigation is not possible.
  24. The nurse will determine that teaching a 67-year-old man to irrigate his new colostomy has been
    effective if the patient
    a. inserts the irrigation tubing 4 to 6 inches into the stoma.
    b. Hangs the irrigating container 18 inches above the stoma.
    c. stops the irrigation and removes the irrigating cone if cramping occurs.
    d. fills the irrigating container with 1000 to 2000 mL of lukewarm tap water.
    ANS: B
    The irrigating container should be hung 18 to 24 inches above the stoma. If cramping occurs, the irrigation
    should be temporarily stopped and the cone left in place. Five hundred to 1000 mL of water should be used
    for irrigation. An irrigation cone, rather than tubing, should be inserted into the stoma; 4 to 6 inches would
    be too far for safe insertion.
  25. A 34-year-old female patient with a new ileostomy asks how much drainage to expect. The nurse
    explains that after the bowel adjusts to the ileostomy, the usual drainage will be about _ cups.
    a. 2
    b. 3
    c. 4
    d. 5
    ANS: A
    After the proximal small bowel adapts to reabsorb more fluid, the average amount of ileostomy
    drainage is about 500 mL daily. One cup is about 240 mL.
  26. The nurse admitting a patient with acute diverticulitis explains that the initial plan of care is to
    a. Administer IV fluids.
    b. give stool softeners and enemas.
    c. order a diet high in fiber and fluids.
    d. prepare the patient for colonoscopy.
    ANS: A
    A patient with acute diverticulitis will be NPO and given parenteral fluids. A diet high in fiber and
    fluids will be implemented before discharge. Bulk-forming laxatives, rather than stool softeners, are
    usually given, and these will be implemented later in the hospitalization. The patient with acute
    diverticulitis will not have enemas or a colonoscopy because of the risk for perforation and peritonitis.
  27. Which activity in the care of a 48-year-old female patient with a new colostomy could the nurse
    delegate to unlicensed assistive personnel (UAP)?
    a. Document the appearance of the stoma.
    b. Place a pouching system over the ostomy.
    c. Drain and measure the output from the ostomy.
    d. Check the skin around the stoma for breakdown.
    ANS: C
    Draining and measuring the output from the ostomy is included in UAP education and scope of practice.
    The other actions should be implemented by LPNs or RNs.
  28. A 33-year-old male patient with a gunshot wound to the abdomen undergoes surgery, and a colostomy
    is formed as shown in the accompanying figure. Which information will be included in patient teaching?
    a. Stool will be expelled from both stomas.
    b. This type of colostomy is usually temporary.
    c. Soft, formed stool can be expected as drainage.
    d. Irrigations can regulate drainage from the stomas.
    ANS: B
    A loop, or double-barrel stoma, is usually temporary. Stool will be expelled from the proximal stoma only.
    The stool from the transverse colon will be liquid and regulation through irrigations will not be possible.
  29. A 72-year-old male patient with dehydration caused by an exacerbation of ulcerative colitis is receiving
    5% dextrose in normal saline at 125 mL/hour. Which assessment finding by the nurse is most important to
    report to the health care provider?
    a. Patient has not voided for the last 4 hours.
    b. Skin is dry with poor turgor on all extremities.
    c. Crackles are heard halfway up the posterior chest.
    d. Patient has had 5 loose stools over the last 6 hours.
    ANS: C
    The presence of crackles in an older patient receiving IV fluids at a high rate suggests volume overload
    and a need to reduce the rate of the IV infusion. The other data will also be reported, but are consistent
    with the patient’s age and diagnosis and do not require a change in the prescribed treatment.
  30. Which menu choice by the patient with diverticulosis is best for preventing diverticulitis?
    a. Navy bean soup and vegetable salad
    b. Whole grain pasta with tomato sauce
    c. Baked potato with low-fat sour cream
    d. Roast beef sandwich on whole wheat bread
    ANS: A
    A diet high in fiber and low in fats and red meat is recommended to prevent diverticulitis. Although all
    of the choices have some fiber, the bean soup and salad will be the highest in fiber and the lowest in fat
  31. Administration of hepatitis B vaccine to a healthy 18-year-old patient has been effective
    when a specimen of the patient’s blood reveals
    a. HBsAg.
    b. anti-HBs.
    c. anti-HBcIgG.
    d. anti-HBcIgM.
    ANS: B
    The presence of surface antibody to HBV (anti-HBs) is a marker of a positive response to the
    vaccine. The other laboratory values indicate current infection with HBV.
  32. The nurse will plan to teach the patient diagnosed with acute hepatitis B about
    a. side effects of nucleotide analogs.
    b. Measures for improving the appetite.
    c. ways to increase activity and exercise.
    d. administeringα-interferon (Intron A).
    ANS: B
    Maintaining adequate nutritional intake is important for regeneration of hepatocytes. Interferon
    and antivirals may be used for chronic hepatitis B, but they are not prescribed for acute hepatitis
    B infection. Rest is recommended.
  33. Which laboratory test result will the nurse monitor when evaluating the effects of therapy
    for a 62-year-old female patient who has acute pancreatitis?
    a. Calcium
    b. Bilirubin
    c. Amylase
    d. Potassium
    ANS: C
    Amylase is elevated in acute pancreatitis. Although changes in the other values may occur, they
    would not be useful in evaluating whether the prescribed therapies have been effective.
  34. Which assessment finding would the nurse need to reportmost quickly to the health care
    provider regarding a patient with acute pancreatitis?
    a. Nausea and vomiting
    b. Hypotonic bowel sounds
    c. Abdominal tenderness and guarding
    d. Muscle twitching and finger numbness
    ANS: D
    Muscle twitching and finger numbness indicate hypocalcemia, which may lead to tetany unless
    calcium gluconate is administered. Although the other findings should also be reported to the
    health care provider, they do not indicate complications that require rapid action.
  35. The nurse will ask a 64-year-old patient being admitted with acute pancreatitis specifically about a
    history of
    a. diabetes mellitus.
    b. high-protein diet.
    c. cigarette smoking.
    d. Alcohol consumption.
    ANS: D
    Alcohol use is one of the most common risk factors for pancreatitis in the United States.
    Cigarette smoking, diabetes, and high-protein diets are not risk factors.
  36. The nurse will teach a patient with chronic pancreatitis to take the prescribed pancrelipase (Viokase)
    a. at bedtime.
    b. in the morning.
    c. with each meal.
    d. for abdominal pain.
    ANS: C
    Pancreatic enzymes are used to help with digestion of nutrients and should be taken with every meal.
  37. The nurse recognizes that teaching a 44-year-old woman following a laparoscopic cholecystectomyhas
    been effective when the patient states which of the following?
    a. “I can expect yellow-green drainage from the incision for a few days.”
    b. “I can remove the bandages on my incisions tomorrow and take a shower.”
    c. “I should plan to limit my activities and not return to work for 4 to 6 weeks.”
    d. “I will always need to maintain a low-fat diet since I no longer have a gallbladder.”
    ANS: B
    After a laparoscopic cholecystectomy, the patient will have Band-Aids in place over the incisions. Patients
    are discharged the same (or next) day and have few restrictions on activities of daily living. Drainage from
    the incisions would be abnormal, and the patient should be instructed to call the health care provider if this
    occurs. A low-fat diet may be recommended for a few weeks after surgery but will not be a life-long
  38. When taking the blood pressure (BP) on the right arm of a patient with severe acute pancreatitis, the
    nurse notices carpal spasms of the patient’s right hand. Which action should the nurse take next?
    a. Ask the patient about any arm pain.
    b. Retake the patient’s blood pressure.
    c. Check the calcium level in the chart.
    d. Notify the health care provider immediately.
    ANS: C
    The patient with acute pancreatitis is at risk for hypocalcemia, and the assessment data indicate a positive
    Trousseau’s sign. The health care provider should be notified after the nurse checks the patient’s calcium
    level. There is no indication that the patient needs to have the BP rechecked or that there is any arm pain.
  39. A 67-year-old male patient with acute pancreatitis has a nasogastric (NG) tube to suction and is
    NPO. Which information obtained by the nurse indicates that these therapies have been effective?
    a. Bowel sounds are present.
    b. Grey Turner sign resolves.
    c. Electrolyte levels are normal.
    d. Abdominal pain is decreased.
    ANS: D
    NG suction and NPO status will decrease the release of pancreatic enzymes into the pancreas and decrease
    pain. Although bowel sounds may be hypotonic with acute pancreatitis, the presence of bowel sounds does
    not indicate that treatment with NG suction and NPO status has been effective. Electrolyte levels may be
    abnormal with NG suction and must be replaced by appropriate IV infusion. Although Grey Turner sign will
    eventually resolve, it would not be appropriate to wait for this to occur to determine whether treatment was
  40. Which assessment finding is of most concern for a 46-year-old woman with acute pancreatitis?
    a. Absent bowel sounds
    b. Abdominal tenderness
    c. Left upper quadrant pain
    d. Palpable abdominal mass
    ANS: D
    A palpable abdominal mass may indicate the presence of a pancreatic abscess, which will require rapid
    surgical drainage to prevent sepsis. Absent bowel sounds, abdominal tenderness, and left upper quadrant
    pain are common in acute pancreatitis and do not require rapid action to prevent further complications.
  41. The nurse is planning care for a 48-year-old woman with acute severe pancreatitis. The
    highestpriority patient outcome is
    a. Maintaining normal respiratory function.
    b. expressing satisfaction with pain control.
    c. developing no ongoing pancreatic disease.
    d. having adequate fluid and electrolyte balance.
    ANS: A
    Respiratory failure can occur as a complication of acute pancreatitis, and maintenance of adequate
    respiratory function is the priority goal. The other outcomes would also be appropriate for the patient.
  42. Which assessment information will be most important for the nurse to report to the health care provider
    about a patient with acute cholecystitis?
    a. The patient’s urine is bright yellow.
    b. The patient’s stools are tan colored.
    c. The patient has increased pain after eating.
    d. The patient complains of chronic heartburn.
    ANS: B
    Tan or grey stools indicate biliary obstruction, which requires rapid intervention to resolve. The other
    data are not unusual for a patient with this diagnosis, although the nurse would also report the other
    assessment information to the health care provider
  43. A 51-year-old woman had an incisional cholecystectomy 6 hours ago. The nurse will place the
    highest priority on assisting the patient to
    a. choose low-fat foods from the menu.
    b. perform leg exercises hourly while awake.
    c. ambulate the evening of the operative day.
    d. Turn, cough, and deep breathe every 2 hours.
    ANS: D
    Postoperative nursing careafter a cholecystectomy focuses on prevention of respiratory complications
    because the surgical incision is high in the abdomen and impairs coughing and deep breathing. The other
    nursing actions are also important to implement but are not as high a priority as ensuring adequate
  44. Which action will the nurse include in the plan of care for a patient who has been diagnosed with
    chronic hepatitis B?
    a. Advise limiting alcohol intake to 1 drink daily.
    b. Schedule for liver cancer screening every 6 months.
    c. Initiate administration of the hepatitis C vaccine series.
    d. Monitor anti-hepatitis B surface antigen (anti-HBs) levels annually.
    ANS: B
    Patients with chronic hepatitis are at higher risk for development of liver cancer, and should be
    screened for liver cancer every 6 to 12 months. Patients with chronic hepatitis are advised to completely
    avoid alcohol. There is no hepatitis C vaccine. Because anti-HBs is present whenever there has been a
    past hepatitis B infection or vaccination, there is no need to regularly monitor for this antibody.
  45. A nurse is considering which patient to admit to the same room as a patient who had a liver transplant
    3 weeks ago and is now hospitalized with acute rejection. Which patient would be the best choice?
    a. Patient who is receiving chemotherapy for liver cancer
    b. Patient who is receiving treatment for acute hepatitis C
    c. Patient who has a wound infection after cholecystectomy
    d. Patient who requires pain management for chronic pancreatitis
    ANS: D
    The patient with chronic pancreatitis doesnot present an infection risk to the immunosuppressed patient
    who had a liver transplant. The other patients either are at risk for infection or currently have an
    infection, which will place the immunosuppressed patient at risk for infection.
  46. In reviewing the medical record shown in the accompanying figure for a patient admitted
    with acute pancreatitis, the nurse sees that the patient has a positive Cullen’s sign. Indicate the
    area where the nurse will assessfor this change.
    a. 1
    b. 2
    c. 3
    d. 4

The area around the umbilicus should be indicated. Cullen’s sign consists of ecchymosis
around the umbilicus. Cullen’s sign occurs because of seepage of bloody exudates from the
inflamed pancreas and indicates severe acute pancreatitis.

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