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Med Surg N241 Exam
ATI Med Surg N241 Exam
Total Questions : 30
Showing 10 questions Sign up for moreThe nurse is admitting a client diagnosed with ascites. Which assessment finding would the nurse anticipate?
Explanation
A) Ascites, the accumulation of fluid in the abdominal cavity, typically presents with weight gain rather than weight loss.
B) Ascites often accompanies peripheral edema, particularly in the lower extremities.
C) Ascites is not typically associated with flushed skin; rather, it may lead to pallor due to anemia or jaundice due to liver dysfunction.
D) Ascites is not directly associated with vomiting blood; hematemesis may indicate complications such as esophageal varices, which can occur in advanced liver disease.
When planning care for a client receiving an enteral feeding via jejunostomy tube, which intervention would the nurse include?
Explanation
A) Monitoring for hypertension is not directly related to caring for a client with enteral feeding via a jejunostomy tube.
B) Measuring residual volume is a nursing intervention for clients with gastric feeding tubes, not jejunostomy tubes.
C) Diarrhea is a potential complication of enteral feeding, and monitoring stool output is essential to assess for this complication and adjust feeding accordingly.
D) Monitoring blood glucose levels is important for clients with diabetes but is not specific to caring for a client with enteral feeding via a jejunostomy tube.
The client with acute pancreatitis asks why she is taking omeprazole. What is the nurse's best response?
Explanation
A) Omeprazole is not primarily prescribed to enhance nutrient absorption; its main action is to reduce gastric acid secretion.
B) Omeprazole does not specifically affect carbohydrate digestion.
C) Omeprazole is a proton pump inhibitor that reduces the production of gastric acid, which can help alleviate symptoms and promote healing in acute pancreatitis.
D) Omeprazole's primary action is not to reduce the risk of pancreatic infection; it is primarily used to decrease gastric acid production
The nurse is preparing a client presentation regarding pancrelipase (Viokase) therapy. Which information would the nurse include in the teaching session?
Explanation
A) Pancrelipase is an enzyme replacement therapy used to aid in the digestion of fats, proteins, and carbohydrates, and its use may lead to steatorrhea (fatty stools) as a common side effect.
B) Pancrelipase is typically administered with meals or snacks to aid in digestion; there is no need to administer it prior to antacids.
C) Pancrelipase is taken with meals or snacks to assist in digestion, so this statement is incorrect.
D) There is no need to rinse the mouth after taking pancrelipase; it is a medication designed for oral ingestion.
A nurse is admitting a client who has acute pancreatitis. Which of the following provider prescriptions should the nurse anticipate?
Explanation
A) Pancrelipase may be prescribed to aid in digestion in chronic pancreatitis but is not typically used in the acute phase.
B) While ambulation may be encouraged as tolerated, it is not a specific prescription for acute pancreatitis.
C) Pantoprazole, a proton pump inhibitor, is often prescribed in acute pancreatitis to reduce gastric acid secretion, thereby reducing pancreatic stimulation and promoting healing.
D) In acute pancreatitis, dietary intake is typically restricted initially, often starting with nothing by mouth (NPO) and progressing to a clear liquid diet as tolerated; a low-residue diet is usually introduced at a later stage.
The nurse is making a home visit to a client with chronic pancreatitis. Which data is consistent with this diagnosis?
Explanation
A) Weight loss is a common symptom of chronic pancreatitis due to malabsorption and decreased appetite.
B) Cool, clammy skin is not typically associated with chronic pancreatitis; it may indicate other conditions such as shock or hypotension.
C) Bruising on the flank is not a typical finding in chronic pancreatitis; it may suggest trauma or other underlying conditions.
D) Ascites, the accumulation of fluid in the abdominal cavity, is more commonly associated with advanced liver disease rather than chronic pancreatitis.
A female client is visiting the Medical Clinic with suspected hepatitis C. Which assessment question should the nurse ask this client?
Explanation
A) Bowel pattern changes are not typically associated with hepatitis C.
B) Hepatitis C can be transmitted through blood transfusions received before widespread screening for the virus.
C) Travel history is not directly relevant to assessing for hepatitis C transmission.
D) While diabetes can be a comorbidity associated with hepatitis C, it is not a primary assessment question for suspected hepatitis C.
The nurse receives report for a client with acute pancreatitis on hospital day 2: NPO with NGT to low intermittent suction, VS: 110/60, 99.2°F-97- 22, 0.9% NS infusing at 125 mL/hour, and IV antibiotics have been started. Chart review reveals the following current laboratory results. Which is a priority for the nurse to report to the healthcare provider?
Explanation
A) While an elevated WBC count may indicate infection, it is not unexpected in acute pancreatitis.
B) Serum potassium within normal range does not require immediate intervention.
C) Serum albumin within normal range does not require immediate intervention.
D) Lipase levels significantly elevated above the normal range indicate ongoing pancreatic inflammation and may require intervention or adjustment of treatment.
When planning care for a client with acute pancreatitis, which order would the nurse anticipate that will contribute to pain control?
Explanation
A) Pancreatic enzymes are typically used to aid in digestion rather than pain control in acute pancreatitis.
B) Decompression of the gastrointestinal tract through nasogastric suction can help reduce pancreatic stimulation and alleviate pain in acute pancreatitis.
C) While ambulation may help prevent complications, it is not directly related to pain control in acute pancreatitis.
D) A clear liquid diet may be initiated once the acute phase has resolved, but it does not directly contribute to pain control.
A client with cirrhosis has the following current assessment data: jaundice, decreased appetite, hemoglobin 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?
Explanation
A) Cirrhosis can lead to coagulopathy due to impaired synthesis of clotting factors by the liver, putting the client at high risk for bleeding.
B) While clients with cirrhosis may experience fatigue, it is not the priority problem indicated by the assessment data provided.
C) Decreased appetite and jaundice may affect nutritional status, but they do not pose an immediate threat compared to the risk of bleeding.
D) Jaundice can lead to pruritus and increased risk of skin breakdown, but it is not the priority problem indicated by the assessment data provided.
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