CCN Quizzes Flashcards
(35 cards)
A nurse is caring for a patient with liver
failure and is performing an assessment in
the knowledge of the patient’s increased
risk of bleeding. The nurse recognizes that
this risk is related to the patient’s inability
to synthesize prothrombin in the liver.
What factor most likely contributes to this
loss of function?
a. Alterations in glucose metabolism
b. Retention of bile salts
c. Inadequate production of albumin
by hepatocytes
d. Inability of the liver to use vitamin K
d. Inability of the liver to use vitamin K
A nurse is performing an admission
assessment of a patient with a diagnosis
of cirrhosis. What technique should the
nurse use to palpate the patient’s liver?
a. Place hand under the right lower
abdominal quadrant and press
down lightly with the other hand.
b. Place the left hand over the
abdomen and behind the left side
at the 11th rib.
c. Place hand under right lower rib
cage and press down lightly with
the other hand.
d. Hold hand 90 degrees to right side
of the abdomen and push down
firmly.
c. Place hand under right lower rib
cage and press down lightly with
the other hand.
The nurse is caring for a 55-year- old
man patient with acute pancreatitis
resulting from gallstones. Which clinical
manifestation would the nurse expect the
patient to exhibit?
a. Hematochezia
b. Left upper abdominal pain
c. Ascites and peripheral edema
d. Temperature over 1020 F (38.90 C
b. Left upper abdominal pain
A nurse is completing the admission
assessment of a client who has acute
pancreatitis. Which of the following
findings is the priority to be reported to the
provider?
a. History of cholelithiasis
b. Serum amylase levels three times
greater than the expected value
c. Client report of severe pain
radiating to the back that is rated at
an “8”
d. Hand spasms present when blood
pressure is checked
d. Hand spasms present when blood
pressure is checked
A nurse is completing an admission
assessment of a client who has
pancreatitis. Which of the following is an
expected finding?
a. Pain in right upper quadrant
radiating to right shoulder
b. Report of pain being worse when
sitting upright
c. Pain relieved with defecation
d. Epigastric pain radiating to left
shoulder
d. Epigastric pain radiating to left
shoulder
A nurse is reviewing the health record of
a client who has pancreatitis. The physical
exam report by the provider indicates the
presence of Cullen’s sign. Which of the
following is an appropriate action by the
nurse to identify this finding?
a. Tap lightly at the costovertebral
margin on the client’s back.
b. Palpate the client’s right lower
quadrant.
c. Inspect the skin around the
umbilicus
d. Auscultate the area below the
client’s scapula.
c. Inspect the skin around the
umbilicus
Pancreatitis is commonly characterized
by:
a. Edema and inflammation.
b. Pleural effusion.
c. Sepsis.
d. Disseminated intravascular
coagulopathy.
a. Edema and inflammation.
A major symptom of pancreatitis that
brings the patient to medical care is:
a. Severe abdominal pain.
b. Fever.
c. Jaundice.
d. Mental agitation
a. Severe abdominal pain.
The nurse should assess for an
important early indicator of acute
pancreatitis, which is a prolonged and
elevated level of:
a. Serum calcium.
b. Serum lipase.
c. Serum bilirubin.
d. Serum amylase.
b. Serum lipase.
Nursing measures for pain relief for
pancreatitis include:
a. Encouraging bed rest to decrease
metabolic rate.
b. Teaching the patient about the
correlation between alcohol intake
and pain.
c. Withholding oral feedings to limit
the release of secretin.
d. All of the above.
d. All of the above.
Which of the following diagnostic
studies could identify an increase in the
diameter of the pancreas?
a. X-ray.
b. Hemoglobin and hematocrit levels.
c. Ultrasound.
d. Serum amylase.
c. Ultrasound.
Which of the following is considered a
“hallmark” symptom of pancreatitis?
a. Vomiting
b. Mid-epigastric pain that radiates to
the back
c. Gradual onset of pain
d. Alcohol consumption
b. Mid-epigastric pain that radiates to
the back
A 54-year-old patient admitted with
diabetes mellitus, malnutrition,
osteomyelitis, and alcohol abuse has a
serum amylase level of 280 U/L and a
serum lipase level of 310 U/L. To what
diagnosis does the nurse attribute these
findings?
a. Malnutrition
b. Osteomyelitis
c. Alcohol abuse
d. Diabetes mellitus
c. Alcohol abuse
Which of the following can be used in
the treatment of acute pancreatitis?
Select all that apply.
a. Parenteral fluids
b. Nasogastric suctioning
c. Corticosteroids
d. H2 receptor antagonists
e. Narcotics or Demerol
f. Surgical resection of the pancreas
a. Parenteral fluids
b. Nasogastric suctioning
d. H2 receptor antagonists
e. Narcotics or Demerol
Which lab test result would indicate
that Mr. Walker has acute pancreatitis?
a. Elevated bilirubin levels
b. Elevated serum lipase and amylase
levels
c. Low white blood cell count
d. Elevated blood alcohol level
b. Elevated serum lipase and amylase
levels
The client diagnosed with acute
pancreatitis is in pain. Which position
should the nurse assist the client to
assume to help decrease the pain?
a. Recommend lying in the prone
position with legs extended.
b. Maintain a tripod position over the
bedside table.
c. Place in side-lying position with
knees flexed.
d. Encourage a supine position with a
pillow under the knees.
c. Place in side-lying position with
knees flexed.
The patient with sudden pain in the left
upper quadrant radiating to the back and
vomiting was diagnosed with acute
pancreatitis. What intervention(s) should
the nurse expect to include in the patient’s
plan of care?
a. Immediately start enteral feeding
to prevent malnutrition.
b. Insert an NG and maintain NPO
status to allow pancreas to rest.
c. Initiate early prophylactic
antibiotic therapy to prevent
infection.
d. Administer acetaminophen
(Tylenol) every 4 hours for pain
relief.
b. Insert an NG and maintain NPO
status to allow pancreas to rest.
. The client with an acute exacerbation of
chronic pancreatitis has a nasogastric
tube and is NPO. Which interventions
should the nurse implement? Select all
that apply.
a. Monitor the bowel sounds.
b. Weigh the client daily.
c. Assess the intravenous site.
d. Provide oral and nasal care.
e. Monitor the blood glucose.
a. Monitor the bowel sounds.
c. Assess the intravenous site.
d. Provide oral and nasal care.
e. Monitor the blood glucose.
Pancreatitis is commonly characterized
by:
a. Edema and inflammation.
b. Pleural effusion.
c. Sepsis.
d. Disseminated intravascular
coagulopathy.
a. Edema and inflammation.
The nurse is discussing complications
of chronic pancreatitis with a client
diagnosed with the disease. Which
complication should the nurse discuss
with the client?
a. Diabetes insipidus.
b. Crohn’s disease.
c. Narcotic addiction.
d. Peritonitis.
c. Narcotic addiction.
The nurse is caring for a 55- year-old
man patient with acute pancreatitis
resulting from gallstones. Which clinical
manifestation would the nurse expect the
patient to exhibit?
a. Hematochezia
b. Left upper abdominal pain
c. Ascites and peripheral edema
d. Temperature over 1020 F (38.90 C)
b. Left upper abdominal pain
A nurse is completing the admission
assessment of a client who has acute
pancreatitis. Which finding is the first
priority?
a. History of cholelithiasis
b. Elevated serum amylase levels
c. Decrase in bowel sounds upon
auscultation
d. Hand spasms present when blood
pressure is checked
d. Hand spasms present when blood
pressure is checked
A nurse is completing an admission
assessment of a client who has
pancreatitis. Which of the following
findings should the nurse expect?
a. Pain in the UQ rating to the
shoulder
b. Report of pain being worse when
sitting upright
c. Pain relieved with defecation
d. Epigastric pain radiating to the left
shoulder
d. Epigastric pain radiating to the left
shoulder
The client is diagnosed with acute
pancreatitis. Which health-care provider’s
admitting order should the nurse
question?
a. Bed rest with bathroom privileges.
b. Initiate IV therapy at D5W 125
mL/hr.
c. Weigh client daily.
d. Low-fat, low-carbohydrate diet.
d. Low-fat, low-carbohydrate diet.
