Question

The nurse is admitting a client diagnosed with ascites. Which assessment finding would the nurse anticipate?

Answer 1

Correct Answers:

Pedal edema

Rationale :

🔸Clients with ascites often exhibit fluid overload symptoms, including pedal edema, due to portal hypertension and hypoalbuminemia associated with liver dysfunction.

🔸Fluid shifts into the peritoneal cavity and interstitial spaces cause peripheral swelling, especially in dependent areas.

🔸Weight loss and flushed skin are not typical, and hematemesis may occur in liver disease but is not directly linked to ascites.

🔸Recognition of edema helps in monitoring disease progression and guiding diuretic therapy.

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Answer 2

Correct Answers:

Check stools for diarrhea

Rationale :

A common complication of enteral feeding via jejunostomy tube is diarrhea, due to rapid nutrient infusion into the small intestine.
The nurse must monitor bowel movements closely to detect malabsorption, formula intolerance, or infection.
Timely detection helps prevent fluid and electrolyte imbalances and supports appropriate adjustments to feeding regimens.

📌Checking residuals is not done for jejunostomy tubes, as there is no gastric reservoir involved.

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Answer 3

Correct Answers:

"This medication will decrease gastric acid secretion."

Rationale :

🧠 Omeprazole is a proton pump inhibitor (PPI) used to suppress gastric acid production.

In acute pancreatitis, reducing gastric acid helps decrease stimulation of pancreatic enzyme secretion, promoting pancreatic rest and healing.
It also protects the gastrointestinal mucosa, which may be vulnerable during systemic inflammation.
This mechanism contributes to overall symptom relief and prevention of further complications such as ulcers or gastrointestinal bleeding.

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Answer 4

Correct Answers:

Administer prior to antacids

Rationale :

✅Pancrelipase (Viokase) contains digestive enzymes that assist in the absorption of fats, proteins, and carbohydrates in clients with pancreatic insufficiency.

It should be administered prior to meals and before antacids, as alkaline environments are required for optimal enzyme activity.
Antacids can inactivate the enzymes if taken concurrently.
Timing and administration are crucial for nutritional absorption and symptom control, especially in chronic pancreatitis.

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Answer 5

Correct Answers:

Pantoprazole 80 mg IV bolus twice daily

Rationale :

Pantoprazole, a proton pump inhibitor, is often prescribed in acute pancreatitis to decrease gastric acid secretion, thereby minimizing pancreatic stimulation.
This reduces pain and risk of complications, including stress ulcers.
The use of PPIs is part of supportive care that helps protect the gastrointestinal tract during acute inflammation.

📌Other listed interventions like pancrelipase or diet advancement are typically not initiated during the acute phase.

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Answer 6

Correct Answers:

Weight loss

Rationale :

✅In chronic pancreatitis, clients commonly experience weight loss due to malabsorption of nutrients and persistent abdominal pain that limits intake.

Pancreatic enzyme insufficiency leads to poor digestion, especially of fats, contributing to nutritional deficiencies and steatorrhea.
Weight loss is a classic sign and a key component in diagnosis and ongoing management. Monitoring nutritional status is essential in long-term care.

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Answer 7

Correct Answers:

"Have you ever had a blood transfusion?"

Rationale :

🔹The nurse should prioritize asking about blood transfusions because hepatitis C is most commonly transmitted through blood exposure, and unscreened transfusions before 1992 were a major transmission route.

🔹 This question directly identifies a key risk factor, unlike bowel patterns or diabetes, which are unrelated to HCV acquisition.

While travel history could hint at hepatitis A or E, it's less relevant for hepatitis C which spreads through blood contact rather than contaminated food/water.
Focusing on transfusion history efficiently screens for potential exposure while ruling out unrelated health issues.

🔹This targeted approach aligns with CDC guidelines emphasizing bloodborne transmission risks for HCV diagnosis.

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Answer 8

Correct Answers:

Lipase 900 u/L (20-180 u/L)

Rationale :

A lipase level of 900 u/L is critically elevated and confirms active pancreatic inflammation, making it the priority lab result to report.
Elevated lipase is more specific and sensitive for diagnosing acute pancreatitis than amylase and can correlate with severity.
Prompt reporting ensures the provider can evaluate the need for additional diagnostics or interventions to manage ongoing inflammation or complications.

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Answer 9

Correct Answers:

Maintain nasogastric tube to intermittent suction

Rationale :

✅ Pain in acute pancreatitis is often worsened by pancreatic stimulation from food or gastric secretions.

An NG tube with intermittent suction helps decompress the stomach, reduce gastric acid, and prevent nausea or vomiting, thereby promoting pancreatic rest.
This intervention is particularly beneficial when the client is NPO and in the early stages of treatment.
It directly contributes to pain relief by minimizing enzyme activation.

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Answer 10

Correct Answers:

Risk of bleeding

Rationale :

🔸A prolonged PT of 20.6 seconds indicates a significant coagulation defect, likely due to impaired liver synthesis of clotting factors in cirrhosis.

🔸When hemoglobin is within the normal range, the risk of spontaneous or procedure-related bleeding is high.

🔸This takes precedence over other issues like nutrition or skin integrity because bleeding can become life-threatening.

🔸Monitoring and correcting coagulopathy with vitamin K or plasma may be necessary.

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RN Medsurg Nurs 241

No.

1 : The nurse is admitting a client diagnosed with ascites. Which assessment finding would the nurse anticipate?

2 : When planning care for a client receiving an enteral feeding via jejunostomy tube, which intervention would the nurse include?

3 : The client with acute pancreatitis asks why she is taking omeprazole. What is the nurse's best response?

4 : The nurse is preparing a client presentation regarding pancrelipase (Viokase) therapy. Which information would the nurse include in the teaching session?

5 : A nurse is admitting a client who has acute pancreatitis. Which of the following provider prescriptions should the nurse anticipate?

6 : The nurse is making a home visit to a client with chronic pancreatitis. Which data is consistent with this diagnosis?

7 : A female client is visiting the Medical Clinic with suspected hepatitis C. Which assessment question should the nurse ask this client?

9 : When planning care for a client with acute pancreatitis, what order would the nurse anticipate that will contribute to pain control?

10 : A client with cirrhosis has the following current assessment data: jaundice, decreased appetite, hemoglobin of 15 g/dL (14-18 g/dL), and PT of 20.6 seconds (11-12.5 sec). What does the nurse identify as the priority problem for this client?

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