ATI Care of Patients with Problems of the Biliary System and Pancreas, Questions and Answers with Explanations
1. The client with obstructive jaundice
... [Show More] asks the nurse why his skin is so itchy. Which is the nurse’s best response?
a. “Bile salts accumulate in the skin and cause the itching.”
b. “Toxins released from an inflamed gallbladder lead to itching.”
c. “Itching is caused by the release of calcium into the skin.”
d. “Itching is caused by a hypersensitivity reaction.”
ANS: A
In obstructive jaundice, the normal flow of bile into the duodenum is blocked, allowing excess bile salts to accumulate on the skin. This leads to itching, or pruritus. The other statements are not accurate.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 1316
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Teaching/Learning
2. The nurse is caring for a client with cholecystitis. Which assessment finding indicates to the nurse that the condition is chronic rather than acute?
a. Abdomen that is hyperresonant to percussion
b. Hyperactive bowel sounds and diarrhea
c. Clay-colored stools and dark amber urine
d. Rebound tenderness in the right upper quadrant
ANS: C
In chronic cholecystitis, bile duct obstruction results in the absence of urobilinogen to color the stool. Excess circulating bilirubin turns the urine dark and foamy. The other assessment findings do not correlate with chronic cholecystitis.
DIF: Cognitive Level: Knowledge/Remembering REF: Chart 62-1, p. 1317
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
3. A client is admitted for suspected cholecystitis. On reviewing laboratory results, the nurse notes that the client’s amylase is elevated. Which action by the nurse is best?
a. Document the finding in the chart.
b. Ask the client about drinking habits.
c. Notify the health care provider.
d. Place the client on clear liquids.
ANS: B
Serum and urine amylase levels are elevated when the pancreas becomes inflamed. One cause of pancreatitis is gallbladder disease; another causative factor is alcohol intake. The nurse should tactfully explore this subject with the client before documenting the findings and notifying the provider. The client may need to be NPO or on clear liquids, but the nurse does not have enough information yet to determine this.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Values) MSC: Integrated Process: Nursing Process (Assessment)
4. The nurse is providing discharge teaching for a client who has just undergone laparoscopic cholecystectomy surgery. Which statement by the client indicates understanding of the instructions?
a. “I will drink at least 2 liters of fluid a day.”
b. “I need a diet without a lot of fatty foods.”
c. “I should drink fluids between meals rather than with meals.”
d. “I will avoid concentrated sweets and simple carbohydrates.”
ANS: B
After cholecystectomy, clients need a nutritious diet without a lot of excess fat; otherwise a special diet is not recommended for most clients. Good fluid intake is healthy for all people but is not related to the surgery. Drinking fluids between meals helps with dumping syndrome, which is not seen with this operation. Restriction of sweets is not required.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Nutrition and Oral Hydration) MSC: Integrated Process: Teaching/Learning
5. The nurse is caring for a client who has just undergone traditional cholecystectomy surgery and has a Jackson-Pratt (JP) drain in place. The nurse notes serosanguineous drainage present in the drain. Which is the nurse’s priority action?
a. Gently milk the drain tubing.
b. Notify the surgeon immediately.
c. Document the finding in the client’s chart.
d. Irrigate the drain with sterile normal saline.
ANS: C
Drainage from the JP drain initially appears serosanguineous in color. The drainage will appear bile-colored within 24 hours. The nurse does not need to notify the surgeon, milk the tubing, or irrigate the drain because this is an expected finding.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC: Integrated Process: Nursing Process (Implementation)
6. The nurse is providing discharge teaching for a client who will be going home with a T-tube following cholecystectomy surgery. Which statement by the client indicates the need for additional teaching?
a. “I will keep the drainage bag lower than the tube itself.”
b. “I will inspect the T-tube drainage site daily for signs of infection.”
c. “I will be careful not to pull on the tube or to accidentally pull it out.”
d. “I will slowly pull about an inch of the tube out each day until it’s out.”
ANS: D
The provider will discontinue the T-tube. The other statements are accurate.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Diagnostic Tests/Treatments/Procedures)
MSC: Integrated Process: Nursing Process (Evaluation)
7. The nurse is caring for a postoperative client who reports pain in the shoulder blades following laparoscopic cholecystectomy surgery. Which direction does the nurse give to the nursing assistant to help relieve the client’s pain?
a. “Ambulate the client in the hallway.”
b. “Apply a cold compress to the client’s back.”
c. “Encourage the client to take sips of hot tea or broth.”
d. “Remind the client to cough and deep breathe every hour.”
ANS: A
The client who has undergone a laparoscopic cholecystectomy may report free air pain because of retention of carbon dioxide in the abdomen. The nurse assists the client with early ambulation to promote absorption of the carbon dioxide. Coughing and deep breathing are important postoperative activities, but they are not related to discomfort from carbon dioxide. Cold compresses and drinking tea would not be helpful.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Delegation) MSC: Integrated Process: Communication and Documentation
8. The nurse is teaching a client with a history of cholelithiasis to select menu items for dinner. Which selections made by the client indicate that the nurse’s teaching was effective?
a. Lasagna, tossed salad with Italian dressing, 2% milk
b. Grilled cheese sandwich, tomato soup, coffee with cream
c. Caesar salad with chicken, soft breadstick with butter, diet cola
d. Roasted chicken breast, baked potato with chives, hot tea with sugar
ANS: D
Clients with cholelithiasis should avoid foods high in fat and cholesterol, such as whole milk, butter, and fried foods. Lasagna, 2% milk, grilled cheese, cream, and butter all have high levels of fat. The meal with the least amount of fat is the chicken breast dinner.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Nursing Process (Evaluation)
9. The nurse is caring for a client who had a T-tube placed 3 days ago. Which assessment finding indicates to the nurse that the procedure was successful?
a. Sclera that is slightly icteric
b. Positive Blumberg’s sign
c. Soft, brown, formed stool this morning
d. Sips of clear liquid tolerated without nausea
ANS: C
A transhepatic biliary catheter (T-tube) decompresses extrahepatic ducts to promote the flow of bile. When bile flows normally, it reaches the large intestine, where bile is converted to urobilinogen, coloring the stools brown. The other findings would not indicate successful T-tube placement.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Therapeutic Procedures) MSC: Integrated Process: Nursing Process (Evaluation)
10. The nurse is caring for a client with acute pancreatitis. During the physical assessment, the nurse notes a grayish-blue discoloration of the client’s flanks. Which is the nurse’s priority action?
a. Prepare the client for emergency surgery.
b. Place the client in high Fowler’s position.
c. Insert a nasogastric (NG) tube to low intermittent suction.
d. Ensure that the client has a patent large-bore IV site.
ANS: D
Grayish-blue discoloration on the flanks (Turner’s sign) indicates pancreatic enzyme leakage into the peritoneal cavity. This presents a risk of shock for the client, so IV access should be maintained with at least one large-bore patent IV catheter. The client may or may not need surgery; usually a fetal position helps with pain, and having an NG tube would not take priority over IV access.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Implementation)
11. The nurse is caring for a client with acute pancreatitis. Which nursing intervention best reduces discomfort for the client?
a. Administering morphine sulfate IV every 4 to 6 hours as needed
b. Maintaining NPO status for the client with IV fluids
c. Providing small, frequent feedings, with no concentrated sweets
d. Placing the client in semi-Fowler’s position at elevation of 30 degrees
ANS: B
The client should be kept NPO to reduce GI activity and reduce pancreatic enzyme production. IV fluids should be used to prevent dehydration. The client may need a nasogastric (NG) tube. Pain medications should be given around the clock and more frequently than every 4 to 6 hours. A fetal position with legs drawn up to the chest will promote comfort.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC: Integrated Process: Nursing Process (Implementation)
12. The nurse is caring for a client who has undergone surgery to drain a pancreatic pseudocyst with placement of a pancreatic drainage tube. Which nursing intervention prevents complications from this procedure?
a. Positioning the client in a right side-lying position
b. Applying a skin barrier around the drainage tube site
c. Clamping the drainage tube for 2 hours every 12 hours
d. Irrigating the drainage [Show Less]