Growth and development NCLEX questions Quizlet related to the subject of a pregnancy test, heart surgery, color vision, ruptured membranes, and Denver screening exam.
The nurse is looking after a newborn’s mother. Because the mother is unfamiliar with cord care, the nurse recognizes that she requires additional instruction.
A. Maintains the cord’s air exposure
B. Before sponge bathing her infant, she washes her hands.
C. At each diaper change, wash thoroughly the cord and surrounding area with water.
D. Check for bleeding and discharge on a daily basis.
The correct answer is C. The rope can be dried by exposing it to air. The most crucial factor in preventing infection is hand washing. Washing the area around the chord is acceptable, but washing it keeps it moist and makes it more susceptible to infection. It’s crucial to keep an eye out for any potential bleeding or drainage issues.
Results
#1. Due to her religious beliefs, the client who has been hospitalized with pancreatitis does not drink alcohol. When the doctor continues to inquire about her alcohol consumption, she grows irritated. The nurse should explain why these questions are being asked
In the United States, alcoholism is a leading cause of acute pancreatitis. Staff may inquire about alcohol consumption in a variety of ways because some clients are hesitant to disclose it. In most cases, drinking alcohol has little effect on the tests used to diagnose pancreatitis. Large amounts of alcohol consumed recently, on the other hand, may produce an increase in serum amylase levels. A high urine amylase concentration can be caused by consuming large amounts of ethyl and methyl alcohol. On admission to the hospital, all patients are asked about their alcohol and drug usage, but this information is especially important for those who have pancreatitis. Physicians must seek facts, but they must do so while respecting the religious views of their patients. In order to provide comprehensive client care, it is critical to respect religious views.
#2. The nurse keeps an eye on the pancreatitis patient for signs of shock. Which of the following conditions is most responsible for making pancreatitis shock difficult to manage?
A potentially fatal consequence of pancreatitis is a life-threatening shock. Vasodilation and enhanced capillary permeability are caused by kinin peptides activated by trapped trypsin. These side effects aggravate shock and are difficult to counteract with pharmacologic treatments like vasopressors. Hemorrhage into the pancreas is possible, but not in the intestines. Pulmonary problems are among the systemic consequences, however, heart failure and acute tubular necrosis are not.
#3. A patient with acute pancreatitis has a blood pressure of 88/40, a heart rate of 128 beats per minute, and breathing rates of 28 per minute, as well as Grey Turner's syndrome. sign. Which of the following actions should the nurse take first?
Grey Turner’s sign is a bluish discoloration in the lower abdomen caused by retroperitoneal bleeding. Hemodynamic instability can be seen in the vital signs. To provide immediate volume replenishment, I.V. access should be secured. The fluid status will be determined by the urine output. Clients with uncontrollable nausea and vomiting, as well as stomach distension, may benefit from a nasogastric tube. Once the client’s vital signs have stabilized, repositioning the client may be explored for pain management.
#4. A patient with acute necrotizing pancreatitis is admitted. A peripheral I.V. has been put once lab findings were acquired. Which of the following health-care provider's orders should the nurse inquire about?
To maintain intestinal integrity and immunological function, clients with acute necrotizing pancreatitis should remain NPO with early enteral feeding via the jejunum. If enteral feedings are not an option, TPN may be considered. TPN requires access as well, preferably via a central line. Hemodynamic instability can be caused by a loss of fluid volume or bleeding, and it needs fluid and electrolyte replacement. Fat necrosis caused by acute pancreatitis can lead to hypocalcemia, which necessitates calcium supplementation. A Foley catheter measures output accurately to check for prerenal acute renal failure, which can arise as a result of hypovolemia.
#5. In the case of a client with acute pancreatitis, which of the following drugs would the nurse inquire about?
Furosemide (Lasix) is a diuretic that can cause pancreatitis. Acute pancreatitis can also cause hypovolemia, and Lasix will deplete fluid volume even more. Imipenem is used to treat acute pancreatitis accompanied by necrosis and infection. Meperidine (Demerol) is no longer preferred over other opiates according to research. Morphine and Dilaudid are the opiates of choice for pain relief in acute pancreatitis. Famotidine is a Histamine 2 receptor antagonist that is used to prevent peptic ulcers and reduce acid secretion.
#6. Which of the following complications should the nurse keep an eye on if the client has acute pancreatitis?
A client with acute pancreatitis is more likely to experience respiratory problems. As a result of pancreatic enzyme exudate, respiratory problems such as pneumonia, atelectasis, and pleural effusion might occur. Heart failure, ulcer formation, or cirrhosis are not caused by pancreatitis.
#7. Which of the following nursing actions would be most suitable for a client who is hospitalized with acute pancreatitis and is experiencing acute abdominal pain? All that apply should be selected.
A client with acute pancreatitis usually suffers from severe stomach pain. The client is placed in a side-lying position, which releases abdominal tension and increases comfort. It’s also OK to take a semi-position. Because pancreatitis patients are more likely to have respiratory issues, the nurse should keep an eye on the client’s respiratory condition. Weights are taken every day to keep track of the client’s dietary and fluid volume condition. While the client will most certainly require opioid analgesics to relieve the pain, morphine sulfate is not recommended because it causes the sphincter of Oddi to spasm, exacerbating the client’s suffering. The pancreas is rested by withholding food and drink during the acute phase of the illness when the client is in discomfort. The diet will be high-carbohydrate, low-fat, and bland when it is reintroduced.
#8. A client with acute pancreatitis may suffer muscle twitching and jerking, according to the nurse. What should the nurse do if these symptoms are significant?
In extreme cases of acute pancreatitis, hypocalcemia develops. The actual reason for this is unknown. Jerking and muscular twitching, numbness of the fingers and lips, and irritability are all signs and symptoms of hypocalcemia. Tremors or seizures are possible side effects of meperidine (Demerol), although muscular twitching is not. Muscle twitching isn’t caused by a dietary deficiency, and it doesn’t mean the customer needs to take a muscle relaxant.
#9. Propantheline bromide (Pro-Banthine) is being given to a patient who is suffering from acute pancreatitis. Which of the following would suggest to the nurse that the drug should be withheld?
Propantheline is an anticholinergic and antispasmodic drug that reduces vagal stimulation and pancreatic production. Because it’s not recommended in paralytic ileus, the nurse should be concerned about the lack of bowel noises. Urinary retention, constipation, and tachycardia are all side effects.
#10. Which of the following dietary suggestions would be suitable for a client recovering from acute pancreatitis to receive from the nurse?
Crash dieting or binge eating should be avoided because it can lead to an abrupt onset of pancreatitis.Because carbs are less stimulating to the pancreas, carbohydrate consumption should be increased.There is no need to stick to a six-meal-a-day diet; the client can eat whenever he or she wants.Because pancreatitis does not induce fluid retention, there is no need to put the client on a sodium-restricted diet.
