Chapter 59: Care of Patients with Problems of the Biliary System and Pancreas Nursing School Test Banks

Chapter 59: Care of Patients with Problems of the Biliary System and Pancreas
Ignatavicius: Medical-Surgical Nursing, 8th Edition

MULTIPLE CHOICE

1. A nurse cares for a client who has obstructive jaundice. The client asks, Why is my skin so itchy? How should the nurse respond?
a. Bile salts accumulate in the skin and cause the itching.
b. Toxins released from an inflamed gallbladder lead to itching.
c. Itching is caused by the release of calcium into the skin.
d. Itching is caused by a hypersensitivity reaction.
ANS: A
In obstructive jaundice, the normal flow of bile into the duodenum is blocked, allowing excess bile salts to accumulate on the skin. This leads to itching, or pruritus. The other statements are not accurate.

DIF: Understanding/Comprehension REF: 1214 KEY: Cholecystitis
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

2. After teaching a client who is recovering from laparoscopic cholecystectomy surgery, the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the teaching?
a. Drinking at least 2 liters of water each day is suggested.
b. I will decrease the amount of fatty foods in my diet.
c. Drinking fluids with my meals will increase bloating.
d. I will avoid concentrated sweets and simple carbohydrates.
ANS: B
After cholecystectomy, clients need a nutritious diet without a lot of excess fat; otherwise a special diet is not recommended for most clients. Good fluid intake is healthy for all people but is not related to the surgery. Drinking fluids between meals helps with dumping syndrome, which is not seen with this procedure. Restriction of sweets is not required.

DIF: Applying/Application REF: 1218
KEY: Cholecystitis| postoperative nursing
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

3. A nurse cares for a client who is recovering from laparoscopic cholecystectomy surgery. The client reports pain in the shoulder blades. How should the nurse respond?
a. Ambulating in the hallway twice a day will help.
b. I will apply a cold compress to the painful area on your back.
c. Drinking a warm beverage can relieve this referred pain.
d. You should cough and deep breathe every hour.
ANS: A
The client who has undergone a laparoscopic cholecystectomy may report free air pain due to retention of carbon dioxide in the abdomen. The nurse assists the client with early ambulation to promote absorption of the carbon dioxide. Cold compresses and drinking a warm beverage would not be helpful. Coughing and deep breathing are important postoperative activities, but they are not related to discomfort from carbon dioxide.

DIF: Applying/Application REF: 1217
KEY: Cholecystitis| postoperative nursing
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

4. After teaching a client who has a history of cholelithiasis, the nurse assesses the clients understanding. Which menu selection made by the client indicates the client clearly understands the dietary teaching?
a. Lasagna, tossed salad with Italian dressing, and low-fat milk
b. Grilled cheese sandwich, tomato soup, and coffee with cream
c. Cream of potato soup, Caesar salad with chicken, and a diet cola
d. Roasted chicken breast, baked potato with chives, and orange juice
ANS: D
Clients with cholelithiasis should avoid foods high in fat and cholesterol, such as whole milk, butter, and fried foods. Lasagna, low-fat milk, grilled cheese, cream, and cream of potato soup all have high levels of fat. The meal with the least amount of fat is the chicken breast dinner.

DIF: Applying/Application REF: 1217
KEY: Cholecystitis| nutritional requirements
MSC: Integrated Process: Nursing Process: Evaluation
NOT: Client Needs Category: Health Promotion and Maintenance

5. A nurse plans care for a client with acute pancreatitis. Which intervention should the nurse include in this clients plan of care to reduce discomfort?
a. Administer morphine sulfate intravenously every 4 hours as needed.
b. Maintain nothing by mouth (NPO) and administer intravenous fluids.
c. Provide small, frequent feedings with no concentrated sweets.
d. Place the client in semi-Fowlers position with the head of bed elevated.
ANS: B
The client should be kept NPO to reduce GI activity and reduce pancreatic enzyme production. IV fluids should be used to prevent dehydration. The client may need a nasogastric tube. Pain medications should be given around the clock and more frequently than every 4 to 6 hours. A fetal position with legs drawn up to the chest will promote comfort.

DIF: Applying/Application REF: 1222
KEY: Pancreatitis| NPO| pain
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

6. After teaching a client who is prescribed pancreatic enzyme replacement therapy, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching?
a. The capsules can be opened and the powder sprinkled on applesauce if needed.
b. I will wipe my lips carefully after I drink the enzyme preparation.
c. The best time to take the enzymes is immediately after I have a meal or a snack.
d. I will not mix the enzyme powder with food or liquids that contain protein.
ANS: C
The enzymes should be taken immediately before eating meals or snacks. If the client cannot swallow the capsules whole, they can be opened up and the powder sprinkled on applesauce, mashed fruit, or rice cereal. The client should wipe his or her lips carefully after drinking the enzyme preparation because the liquid could damage the skin. Protein items will be dissolved by the enzymes if they are mixed together.

DIF: Applying/Application REF: 1224
KEY: Pancreatitis| medication safety
MSC: Integrated Process: Nursing Process: Evaluation
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

7. A nurse assesses a client who is recovering from an open Whipple procedure. Which action should the nurse perform first?
a. Assess the clients endotracheal tube with 40% FiO2.
b. Insert an indwelling Foley catheter to gravity drainage.
c. Place the clients nasogastric tube to low intermittent suction.
d. Start lactated Ringers solution through an intravenous catheter.
ANS: A
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.

DIF: Applying/Application REF: 1230
KEY: Whipple procedure| postoperative nursing
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

8. 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?
a. I dont know. I wish I had an answer for you, but I dont.
b. Its important to keep a positive attitude for your family right now.
c. Scientists have not determined why cancer develops in certain people.
d. I think that this is a trial so you can become a better person because of it.
ANS: A
The client is not asking the nurse to actually explain why the cancer has occurred. The client may be expressing his or her feelings of confusion, frustration, distress, and grief related to this diagnosis. Reminding the client to keep a positive attitude for his or her family does not address the clients emotions or current concerns. The nurse should validate that there is no easy or straightforward answer as to why the client has cancer. Telling a client that cancer is a trial is untrue and may diminish the client-nurse relationship.

DIF: Applying/Application REF: 1230
KEY: Pancreatic cancer| coping| support MSC: Integrated Process: Caring
NOT: Client Needs Category: Psychosocial Integrity

9. A nurse prepares to assess the emotional state of a client with end-stage pancreatic cancer. Which action should the nurse take first?
a. Bring the client to a quiet room for privacy.
b. Pull up a chair and sit next to the clients bed.
c. Determine whether the client feels like talking about his or her feelings.
d. Review the health care providers notes about the prognosis for the client.
ANS: C
Before conducting an assessment about the clients feelings, the nurse should determine whether he or she is willing and able to talk about them. If the client is open to the conversation and his or her room is not appropriate, an alternative meeting space may be located. The nurse should be present for the client during this time, and pulling up a chair and sitting with the client indicates that presence. Because the nurse is assessing the clients response to a terminal diagnosis, it is not necessary to have detailed information about the projected prognosis; the nurse knows that the client is facing an end-of-life illness.

DIF: Applying/Application REF: 1230
KEY: Pancreatic cancer| coping| support MSC: Integrated Process: Caring
NOT: Client Needs Category: Psychosocial Integrity

10. A nurse assesses clients at a community health center. Which client is at highest risk for pancreatic cancer?
a. A 32-year-old with hypothyroidism
b. A 44-year-old with cholelithiasis
c. A 50-year-old who has the BRCA2 gene mutation
d. A 68-year-old who is of African-American ethnicity
ANS: C
Mutations in both the BRCA2 and p16 genes increase the risk for developing pancreatic cancer in a small number of cases. The other factors do not appear to be linked to increased risk.

DIF: Remembering/Knowledge REF: 1227
KEY: Pancreatic cancer| health screening MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

11. A nurse assesses a client who has cholecystitis. Which clinical manifestation indicates that the condition is chronic rather than acute?
a. Temperature of 100.1 F (37.8 C)
b. Positive Murphys sign
c. Light-colored stools
d. Upper abdominal pain after eating
ANS: C
Jaundice, 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.

DIF: Understanding/Comprehension REF: 1215
KEY: Cholecystitis| assessment/diagnostic examination
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

12. 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?
a. Administer intravenous morphine while the client sleeps.
b. Encourage the client to use the PCA pump upon awakening.
c. Contact the provider and request a different analgesic.
d. Ask a family member to initiate the PCA pump for the client.
ANS: B
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. The nurse should also evaluate dosages received compared with dosages requested and contact the provider if the dose or frequency is not adequate. Only the client should push the pain button on a PCA pump.

DIF: Applying/Application REF: 1218
KEY: Cholecystitis| pain| postoperative care
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

13. A nurse cares for a client with acute pancreatitis. The client states, I am hungry. How should the nurse reply?
a. Is your stomach rumbling or do you have bowel sounds?
b. I need to check your gag reflex before you can eat.
c. Have you passed any flatus or moved your bowels?
d. You will not be able to eat until the pain subsides.
ANS: C
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.

DIF: Applying/Application REF: 1219
KEY: Pancreatitis| NPO| assessment/diagnostic examination
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

14. A nurse prepares to discharge a client with chronic pancreatitis. Which question should the nurse ask to ensure safety upon discharge?
a. Do you have a one- or two-story home?
b. Can you check your own pulse rate?
c. Do you have any alcohol in your home?
d. Can you prepare your own meals?
ANS: A
A client recovering from chronic pancreatitis should be limited to one floor until strength and activity increase. The client will need a bathroom on the same floor for frequent defecation. Assessing pulse rate and preparation of meals is not specific to chronic pancreatitis. Although the client should be encouraged to stop drinking alcoholic beverages, asking about alcohol availability is not adequate to assess this clients safety.

DIF: Applying/Application REF: 1223
KEY: Pancreatitis| patient education
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

15. A nurse assesses clients on the medical-surgical unit. Which client should the nurse identify as at high risk for pancreatic cancer?
a. A 26-year-old with a body mass index of 21
b. A 33-year-old who frequently eats sushi
c. A 48-year-old who often drinks wine
d. A 66-year-old who smokes cigarettes
ANS: D
Risk factors for pancreatic cancer include obesity, older age, high intake of red meat, and cigarette smoking. Sushi and wine intake are not risk factors for pancreatic cancer.

DIF: Applying/Application REF: 1227
KEY: Pancreatic cancer| health screening
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

16. A nurse assesses a client who is recovering from a Whipple procedure. Which assessment finding alerts the nurse to urgently contact the health care provider?
a. Drainage from a fistula
b. Absent bowel sounds
c. Pain at the incision site
d. Nasogastric (NG) tube drainage
ANS: A
Complications of a Whipple procedure include secretions that drain from a fistula and peritonitis. Absent bowel sounds, pain at the incision site, and NG tube drainage are normal postoperative findings.

DIF: Applying/Application REF: 1229
KEY: Whipple procedure| postoperative nursing
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

17. A nurse cares for a client who is recovering from an open Whipple procedure. Which action should the nurse take?
a. Clamp the nasogastric tube.
b. Place the client in semi-Fowlers position.
c. Assess vital signs once every shift.
d. Provide oral rehydration.
ANS: B
Postoperative care for a client recovering from an open Whipple procedure should include placing the client in a semi-Fowlers position to reduce tension on the suture line and anastomosis sites, setting the nasogastric tube to low suction to remove free air buildup and pressure, assessing vital signs frequently to assess fluid and electrolyte complications, and providing intravenous fluids.

DIF: Applying/Application REF: 1229
KEY: Whipple procedure| postoperative nursing
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

MULTIPLE RESPONSE

1. A nurse assesses a client who is recovering from a Whipple procedure. Which clinical manifestations alert the nurse to a complication from this procedure? (Select all that apply.)
a. Clay-colored stools
b. Substernal chest pain
c. Shortness of breath
d. Lack of bowel sounds or flatus
e. Urine output of 20 mL/6 hr
ANS: B, C, D, E
Myocardial infarction (chest pain), pulmonary embolism (shortness of breath), adynamic ileus (lack of bowel sounds or flatus), and renal failure (urine output of 20 mL/6 hr) are just some of the complications for which the nurse must assess the client after the Whipple procedure. Clay-colored stools are associated with cholecystitis and are not a complication of a Whipple procedure.

DIF: Understanding/Comprehension REF: 1229
KEY: Whipple procedure| postoperative nursing
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

2. A nurse assesses a client with cholelithiasis. Which assessment findings should the nurse identify as contributors to this clients condition? (Select all that apply.)
a. Body mass index of 46
b. Vegetarian diet
c. Drinking 4 ounces of red wine nightly
d. Pregnant with twins
e. History of metabolic syndrome
f. Glycosylated hemoglobin level of 15%
ANS: A, D, F
Obesity, pregnancy, and diabetes are all risk factors for the development of cholelithiasis. A diet low in saturated fats and moderate alcohol intake may decrease the risk. Although metabolic syndrome is a precursor to diabetes, it is not a risk factor for cholelithiasis. The client should be informed of the connection.

DIF: Remembering/Knowledge REF: 1214
KEY: Cholecystitis| health screening
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

3. A nurse teaches a client who is recovering from acute pancreatitis. Which statements should the nurse include in this clients teaching? (Select all that apply.)
a. Take a 20-minute walk at least 5 days each week.
b. Attend local Alcoholics Anonymous (AA) meetings weekly.
c. Choose whole grains rather than foods with simple sugars.
d. Use cooking spray when you cook rather than margarine or butter.
e. Stay away from milk and dairy products that contain lactose.
f. We can talk to your doctor about a prescription for nicotine patches.
ANS: B, D, F
The client should be advised to stay sober, and AA is a great resource. The client requires a low-fat diet, and cooking spray is low in fat compared with butter or margarine. If the client smokes, he or she must stop because nicotine can precipitate an exacerbation. A nicotine patch may help the client quit smoking. The client must rest until his or her strength returns. The client requires high carbohydrates and calories for healing; complex carbohydrates are not preferred over simple ones. Dairy products do not cause a problem.

DIF: Applying/Application REF: 1223
KEY: Pancreatitis| patient education MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance

4. A nurse cares for a client who presents with tachycardia and prostration related to biliary colic. Which actions should the nurse take? (Select all that apply.)
a. Contact the provider immediately.
b. Lower the head of the bed.
c. Decrease intravenous fluids.
d. Ask the client to bear down.
e. Administer prescribed opioids.
ANS: A, B
Clients who are experiencing biliary colic may present with tachycardia, pallor, diaphoresis, prostration, or other signs of shock. The nurse should stay with the client, lower the clients head, and contact the provider or Rapid Response Team for immediate assistance. Treatment for shock usually includes intravenous fluids; therefore, decreasing fluids would be an incorrect intervention. The clients tachycardia is a result of shock, not pain. Performing the vagal maneuver or administering opioids could knock out the clients compensation mechanism.

DIF: Applying/Application REF: 1215
KEY: Cholecystitis| shock
MSC: Integrated Process: Nursing Process: Intervention
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

5. A nurse plans care for a client who has acute pancreatitis and is prescribed nothing by mouth (NPO). With which health care team members should the nurse collaborate to provide appropriate nutrition to this client? (Select all that apply.)
a. Registered dietitian
b. Nursing assistant
c. Clinical pharmacist
d. Certified herbalist
e. Health care provider
ANS: A, C, E
Clients who are prescribed NPO while experiencing an acute pancreatitis episode may need enteral or parenteral nutrition. The nurse should collaborate with the registered dietitian, clinical pharmacist, and health care provider to plan and implement the more appropriate nutritional interventions. The nursing assistant and certified herbalist would not assist with this clinical decision.

DIF: Applying/Application REF: 1223
KEY: Pancreatitis| collaboration| interdisciplinary health care team
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

6. A nurse collaborates with an unlicensed assistive personnel (UAP) to provide care for a client who is in the healing phase of acute pancreatitis. Which statements focused on nutritional requirements should the nurse include when delegating care for this client? (Select all that apply.)
a. Do not allow the client to eat between meals.
b. Make sure the client receives a protein shake.
c. Do not allow caffeine-containing beverages.
d. Make sure the foods are bland with little spice.
e. Do not allow high-carbohydrate food items.
ANS: B, C, D
During the healing phase of pancreatitis, the client should be provided small, frequent, moderate- to high-carbohydrate, high-protein, low-fat meals. Protein shakes can be provided to supplement the diet. Foods and beverages should not contain caffeine and should be bland.

DIF: Applying/Application REF: 1223
KEY: Pancreatitis| nutritional requirements| collaboration| unlicensed assistive personnel (UAP) MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

7. A nurse cares for a client with pancreatic cancer who is prescribed implanted radioactive iodine seeds. Which actions should the nurse take when caring for this client? (Select all that apply.)
a. Dispose of dirty linen in a red biohazard bag.
b. Place the client in a private room.
c. Wear a lead apron when providing client care.
d. Bundle care to minimize exposure to the client.
e. Initiate Transmission-Based Precautions.
ANS: B, C, D
The client should be placed in a private room and dirty linens kept in the clients room until the radiation source is removed. The nurse should wear a lead apron while providing care, ensuring that the apron always faces the client. The nurse should also bundle care to minimize exposure to the client. Transmission-Based Precautions will not protect the nurse from the implanted radioactive iodine seeds.

DIF: Applying/Application REF: 1228
KEY: Pancreatic cancer| radiation therapy
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

SHORT ANSWER

1. A nurse cares for a client with acute pancreatitis who is prescribed gentamicin (Garamycin) 3 mg/kg/day in 3 divided doses. The client weighs 264 lb. How many milligrams should the nurse administer for each dose? (Record your answer using a whole number.) ____ mg/dose

ANS:
120 mg/dose
264 lb (2.2 lb/kg) = 120 kg.
3 mg/kg/day 120 kg = 360 mg/day.
360 mg/day 3 divided doses = 120 mg/dose.

DIF: Applying/Application REF: 1218 KEY: Medication safety
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

2. A nurse cares for a client who is prescribed 4 mg of calcium gluconate to infuse over 5 hours. The pharmacy provides 2 premixed infusion bags with 2 mg of calcium gluconate in 100 mL of D5W. At what rate should the nurse administer this medication? (Record your answer using a whole number.) ____ mL/hr

ANS:
40 mL/hr

DIF: Applying/Application REF: 1218 KEY: Medication safety
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

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