A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? (Select all that apply)

Diarrhea.

Black tarry stools.

Hyperactive bowel sounds.

Gray-blue color at the flank.

Abdominal guarding and tenderness.

Left upper quadrant pain with radiation to the back.

Answer and Explanation

Correct Answer : D,E,F

Choice A reason: Diarrhea is less common in acute pancreatitis, which typically causes nausea and vomiting. Flank discoloration is a specific sign, making this incorrect, as it’s not a primary finding the nurse would expect in the assessment of acute pancreatitis.

Choice B reason: Black tarry stools indicate upper GI bleeding, not pancreatitis, which causes pain and guarding. Left quadrant pain is typical, making this incorrect, as it’s unrelated to the nurse’s expected findings in a client with suspected acute pancreatitis.

Choice C reason: Hyperactive bowel sounds suggest obstruction, not pancreatitis, which often causes hypoactive sounds due to inflammation. Abdominal tenderness is correct, making this incorrect, as it doesn’t align with the nurse’s anticipated findings in acute pancreatitis assessment.

Choice D reason: Gray, including its reasoning, and a gray-blue flank (Cullen’s or Grey Turner’s sign) indicates severe pancreatitis with hemorrhage. This aligns with severe pancreatitis assessment, making it a correct finding the nurse would expect in suspected acute pancreatitis.

Choice E reason: Abdominal guarding and tenderness result from pancreatic inflammation, common in acute pancreatitis. This aligns with abdominal assessment findings, making it a correct manifestation the nurse would identify in a client with suspected acute pancreatitis.

Choice F reason: Left upper quadrant pain radiating to the back is classic in acute pancreatitis due to pancreatic inflammation. This aligns with clinical assessment, making it a correct finding the nurse would expect in a client with suspected acute pancreatitis.

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Correct Answer is B

Explanation

Choice A reason: A beefy red, shiny stoma is normal, indicating healthy tissue perfusion. Purple discoloration suggests ischemia, making this incorrect, as it doesn’t require immediate notification compared to the nurse’s priority of reporting a potentially life-threatening stoma complication to the provider.

Choice B reason: Purple discoloration of the stoma indicates potential ischemia or necrosis, a serious complication requiring immediate provider notification. This aligns with colostomy care priorities, making it the correct observation for the nurse to report promptly to prevent further tissue damage or obstruction.

Choice C reason: Skin excoriation around the stoma is concerning but less urgent than purple discoloration, which signals ischemia. This is incorrect, as it can be managed with barrier creams, unlike the nurse’s priority of addressing a critical stoma issue requiring immediate intervention.

Choice D reason: Semiformed stool in the ostomy pouch is expected post-colostomy and not alarming. Purple discoloration is critical, making this incorrect, as it’s a normal finding compared to the nurse’s need to notify the provider about a potentially ischemic stoma.

A. Asking the LPN to administer an intramuscular injection to a patient. B. Asking the LPN to assess a post-operative patient’s wound for signs of infection. C. Asking the MA to complete a follow-up call with a patient about test results. D. Asking the MA to insert a nasogastric tube in a patient who requires nutritional support.

Correct Answer is A

Explanation

Choice A reason: Administering an intramuscular injection is within the LPN’s scope of practice, ensuring safe delegation. This aligns with nursing delegation guidelines, making it the correct example of appropriate task assignment for the nurse to delegate to the LPN on a busy unit.

Choice B reason: Assessing a wound for infection requires RN judgment, exceeding the LPN’s scope. Administering an injection is appropriate, making this incorrect, as it’s an improper delegation compared to the nurse’s choice of a task within the LPN’s role.

Choice C reason: MAs cannot discuss test results, as this requires clinical judgment beyond their scope. LPN injection administration is correct, making this incorrect, as it’s an inappropriate task for the MA compared to the nurse’s proper delegation choice.

Choice D reason: Inserting a nasogastric tube is an RN task, not within the MA’s scope. LPN injection administration is appropriate, making this incorrect, as it’s unsafe delegation compared to the nurse’s selection of a task suitable for the LPN.

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A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? (Select all that apply)

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