NCLEX acute pancreatitis questions

NCLEX acute pancreatitis questions

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Students also studied Terms in this set (5) George Brown College Nursing Save Pancreatitis, NCLEX 59 terms melissa-knight Preview Pancreatitis NCLEX Questions 12 terms florahill10Preview Pancreatitis NCLEX (ATI, Evolve, Lew...13 terms Jennster17Preview Diabete Teacher ssa 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?

• Immediately start enteral feeding to prevent

malnutrition.

• Insert an NG and maintain NPO status to allow

pancreas to rest.

• Initiate early prophylactic antibiotic therapy to prevent

infection.

• Administer acetaminophen (Tylenol) every 4 hours for

pain relief.

• Insert an NG and maintain NPO status to allow pancreas to rest.

Initial treatment with acute pancreatitis will include an NG tube if there is vomiting and being NPO to decrease pancreatic enzyme stimulation and allow the pancreas to rest and heal. Fluid will be administered to treat or prevent shock. The pain will be treated with IV morphine because of the NPO status. Enteral feedings will only be used for the patient with severe acute pancreatitis in whom oral intake is not resumed. Antibiotic therapy is only needed with acute necrotizing pancreatitis and signs of infection.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?

• Hematochezia
• Left upper abdominal pain
• Ascites and peripheral edema
• Temperature over 102o F (38.9o C)
• Left upper abdominal pain

Abdominal pain (usually in the left upper quadrant) is the predominant manifestation of acute pancreatitis. Other manifestations of acute pancreatitis include nausea and vomiting, low-grade fever, leukocytosis, hypotension, tachycardia, and jaundice. Abdominal tenderness with muscle guarding is common. Bowel sounds may be decreased or absent. Ileus may occur and causes marked abdominal distention. Areas of cyanosis or greenish to yellow-brown discoloration of the abdominal wall may occur. Other areas of ecchymoses are the flanks (Grey Turner's spots or sign, a bluish flank discoloration) and the periumbilical area (Cullen's sign, a bluish periumbilical discoloration).

• 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?

• History of cholelithiasis
• Serum amylase levels three times greater than the

expected value

• Client report of severe pain radiating to the back that

is rated at an "8"

• Hand spasms present when blood pressure is checked

D. CORRECT: The greatest risk to the client is hypocalcemia due to the risk of

cardiac dysrhythmia. Hand spasms when taking a blood pressure is an indication of hypocalcemia and is the priority finding to report to the provider

• A nurse is completing an admission assessment of a

client who has pancreatitis. Which of the following is an expected finding?

• Pain in right upper quadrant radiating to right shoulder
• Report of pain being worse when sitting upright
• Pain relieved with defecation
• Epigastric pain radiating to left shoulder

D. CORRECT: A client who has pancreatitis will report severe, boring epigastric

pain that radiates to the back, left flank, or 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?

• Tap lightly at the costovertebral margin on the client's

back.

• Palpate the client's right lower quadrant.
• Inspect the skin around the umbilicus.
• Auscultate the area below the client's scapula.

C. CORRECT: Cullen's sign is indicated by a bluish-grey discoloration in the

periumbilical area.