Ch25 Full Test Bank Gallbladder Liver Pancreas Care - Medical Surgical Nursing 7e | Test Bank by LeMone, Burke, Bauldoff by LeMone, Burke, Gerene Bauldoff. DOCX document preview.
LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno)
Chapter 25 Nursing Care of Patients with Gallbladder, Liver, and Pancreatic Disorders
1) The nurse is preparing instructions for a patient who is at risk for cholelithiasis. What lifestyle modification should the nurse include in this teaching?
1. Reduce sodium intake.
2. Increase fluids.
3. Reduce smoking.
4. Reduce fat consumption.
Page Ref: 815
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning
Learning Outcome: 25.1 Describe the pathophysiology and manifestations of gallbladder disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with gallbladder, liver, and pancreatic disorders.
2) The nurse is assessing a patient who is experiencing hepatocellular failure. Which finding best indicates that the patient is developing ascites?
1. Accumulation of fluid in the abdomen
2. Jaundiced skin
3. Ecchymosis
4. Upper-right-quadrant pain
Page Ref: 817
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 25.2 Describe the pathophysiology and manifestations of liver disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with gallbladder, liver, and pancreatic disorders.
3) A patient with hepatitis is receiving interferon alpha. Which manifestation indicates that the patient is experiencing an untoward effect of this medication?
1. Jaundice
2. Flulike syndrome
3. Gallbladder pain
4. Clay-colored stools
Page Ref: 822
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 25.2 Describe the pathophysiology and manifestations of liver disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with gallbladder, liver, and pancreatic disorders.
4) The nurse is teaching a patient about strategies for reducing the risk of hepatitis B transmission. Which patient statement indicates teaching has been effective? Select all that apply.
1. "I will wash my hands frequently to prevent fecal-oral transmission."
2. "I will avoid alcohol."
3. "I will avoid contact with blood and body fluids."
4. "I will avoid contaminated food and water."
5. "I will use safe sex techniques."
Page Ref: 818
Cognitive Level: Analyzing
Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning
Learning Outcome: 25.2 Describe the pathophysiology and manifestations of liver disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with gallbladder, liver, and pancreatic disorders.
5) A patient who has portal systemic encephalopathy is receiving Neomycin (neomycin sulfate). Which manifestation should indicate to the nurse that the patient's condition is improving?
1. Increase in potassium level
2. Asterixis
3. Relief of jaundice
4. Increased level of consciousness
Page Ref: 831
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 25.2 Describe the pathophysiology and manifestations of liver disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with gallbladder, liver, and pancreatic disorders.
6) The nurse is planning care for a patient scheduled for paracentesis to treat ascites. Which outcome should the nurse use for this patient's plan of care?
1. The patient will have normal bilateral breath sounds.
2. The patient's spleen will not rupture.
3. The patient's respiratory effort will be lessened.
4. The patient will not manifest symptoms of hepatomegaly.
Page Ref: 832
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 25.2 Describe the pathophysiology and manifestations of liver disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with gallbladder, liver, and pancreatic disorders.
7) The nurse is instructing a patient recovering from a liver transplant. What should the nurse include in this teaching?
1. Eat a high-protein diet.
2. Reduce scheduled antirejection drugs to every other day if nausea occurs.
3. Take acetaminophen (Tylenol) if fever develops.
4. Report sore throats to the healthcare provider.
Page Ref: 835
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 25.2 Describe the pathophysiology and manifestations of liver disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with gallbladder, liver, and pancreatic disorders.
8) A patient with pancreatitis asks why the stools are frothy and have a foul odor. Which response should the nurse make?
1. "This is a sign of malnutrition."
2. "This indicates your stools have more fat in them."
3. "This is a sign of peptic ulcer disease."
4. "You may be developing diabetes mellitus."
Page Ref: 842
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 25.3 Describe the pathophysiology and manifestations of exocrine pancreas disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with gallbladder, liver, and pancreatic disorders.
9) The nurse is caring for a patient with chronic pancreatitis and a serum amylase level of 180 units/L. Which eating plan should the nurse instruct the patient to follow?
1. Low residue, no alcohol
2. Low fat, no alcohol
3. Low fat, no fiber
4. Mechanical soft
Page Ref: 843
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 25.3 Describe the pathophysiology and manifestations of exocrine pancreas disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with gallbladder, liver, and pancreatic disorders.
10) A patient with epigastric pain has a serum amylase level of 369 units/L. What should the nurse do?
1. Continue to monitor the patient.
2. Refer the patient to a dietician.
3. Contact the primary healthcare provider.
4. Question the patient regarding alcohol use patterns.
Page Ref: 843
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 25.3 Describe the pathophysiology and manifestations of exocrine pancreas disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with gallbladder, liver, and pancreatic disorders.
11) The nurse is caring for a patient with a Sengstaken-Blakemore tube. Which assessment finding should the nurse immediately report for follow-up?
1. Left lower leg swollen and reddened
2. Absent bowel sounds to lower-left quadrant
3. Decreased level of consciousness
4. 3 cm darkened area on left heel
Page Ref: 833-834
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 25.2 Describe the pathophysiology and manifestations of liver disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with gallbladder, liver, and pancreatic disorders.
12) The nurse notes new areas of ecchymosis on the arms and legs of a patient with liver cirrhosis. Which laboratory test result should the nurse monitor because of this finding? Select all that apply.
1. Complete blood count with platelets
2. Coagulation studies
3. Serum albumin
4. Serum ammonia levels
5. Serum hepatitis antibodies
Page Ref: 836
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 25.2 Describe the pathophysiology and manifestations of liver disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with gallbladder, liver, and pancreatic disorders.
13) A patient has ascites caused by liver failure. Which finding should the nurse report for immediate follow-up?
1. Asterixis
2. Jaundice
3. Increased abdominal girth
4. Dyspnea
Page Ref: 832
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment/Communication and Documentation
Learning Outcome: 25.2 Describe the pathophysiology and manifestations of liver disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with gallbladder, liver, and pancreatic disorders.
14) A patient with cirrhosis is experiencing hypertension, edema, and shortness of breath. What should the nurse identify as the patient's priority problem?
1. Insufficient fluid level
2. Problem with tissue perfusion
3. Too much bodily fluid
4. Problem with integumentary status
Page Ref: 829
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 25.2 Describe the pathophysiology and manifestations of liver disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with gallbladder, liver, and pancreatic disorders.
15) A patient with a liver abscess is experiencing nausea and vomiting. Which problem should the nurse identify as a priority for this patient?
1. Too much fluid
2. Not enough fluid
3. Problem breathing
4. Altered self-image
Page Ref: 840
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 25.2 Describe the pathophysiology and manifestations of liver disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with gallbladder, liver, and pancreatic disorders.
16) A patient experiences severe, steady pain in the epigastric area, nausea, and vomiting after eating barbecue ribs. What should the nurse consider as the most likely cause of the patient's symptoms?
1. Intolerance to pork
2. Obesity
3. Cholelithiasis
4. Pancreatitis
Page Ref: 811
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 25.1 Describe the pathophysiology and manifestations of gallbladder disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with gallbladder, liver, and pancreatic disorders.
17) A patient with cholelithiasis has a serum amylase level of 300 units/L. What should the nurse consider as the most likely explanation for the laboratory finding?
1. The gallstone is causing acute cholecystitis.
2. The gallstone has migrated to the neck of the pancreas.
3. The gallstone has caused bile to back into the pancreas.
4. The gallstone is blocking the common bile duct.
Page Ref: 841
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 25.3 Describe the pathophysiology and manifestations of exocrine pancreas disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with gallbladder, liver, and pancreatic disorders.
18) The nurse is assessing a patient with cholelithiasis. Which patient statement indicates a progression to cholecystitis? Select all that apply.
1. "I've been in terrible pain for 2 hours."
2. "I'm hot and sweating, then cold and shivering."
3. "The pain's in the same location as when I had appendicitis."
4. "I need an emesis basin; I've vomited four times."
5. "My abdomen and my back both hurt."
Page Ref: 812
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 25.1 Describe the pathophysiology and manifestations of gallbladder disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with gallbladder, liver, and pancreatic disorders.
19) The nurse has instructed a patient about the possible complications of unresolved cholecystitis. Which patient statement indicates that teaching has been effective? Select all that apply.
1. "I could have infected pus stored in my gallbladder."
2. "My gallbladder could rot and cause a big infection in my abdomen."
3. "A hole could form a connection between my gallbladder and intestines."'
4. "My intestines could be blocked with a gallstone."
5. "My gallbladder could turn inside out into the bile duct."
Page Ref: 812
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning
Learning Outcome: 25.1 Describe the pathophysiology and manifestations of gallbladder disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with gallbladder, liver, and pancreatic disorders.
20) A patient has abdominal pain and a serum conjugated bilirubin level of 1.2 mg/dL. What should the nurse suspect is occurring with this patient?
1. A disease that requires phototherapy
2. A disorder that causes large amounts of red blood cell death
3. A disorder of the biliary system
4. A small bowel obstruction
Page Ref: 812
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 25.1 Describe the pathophysiology and manifestations of gallbladder disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with gallbladder, liver, and pancreatic disorders.
21) A patient scheduled for a laparoscopic cholecystectomy asks the nurse why a surgical consent for a laparotomy must also be completed. How should the nurse respond?
1. "By signing both now, you'll never have to sign another one. We'll keep the extra on file for the future."
2. "Surgeons base their decision on whether to do the procedure laparoscopically or with a full incision on many factors. With this signed, the surgeon has options."
3. "You will be ready if the laparoscopic operating rooms are busy today."
4. "The surgeon will start the procedure laproscopically but may need to make an incision to complete the procedure."
Page Ref: 813
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 25.1 Describe the pathophysiology and manifestations of gallbladder disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with gallbladder, liver, and pancreatic disorders.
22) A patient has been given instructions about a laparoscopic cholecystectomy. Which patient statement indicates further teaching is needed?
1. "I should be able to go home within a day after the procedure."
2. "I will probably have bandages over the puncture sites."
3. "I am glad I won't need to have an open cholecystectomy."
4. "I will tell the nurse if I feel nauseated after surgery."
Page Ref: 813
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning
Learning Outcome: 25.1 Describe the pathophysiology and manifestations of gallbladder disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with gallbladder, liver, and pancreatic disorders.
23) The nurse is teaching a patient with an acute attack of cholecystitis about nutritional interventions. Which patient statement indicates additional teaching is required?
1. "I need to stop eating and drinking everything for a while."
2. "I may need a tube inserted into my nose that goes all the way into my stomach."
3. "I may be prescribed vitamins B and C."
4. "I may need extra bile salts to promote health."
Page Ref: 813
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning
Learning Outcome: 25.1 Describe the pathophysiology and manifestations of gallbladder disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with gallbladder, liver, and pancreatic disorders.
24) A patient wants to reduce the risk of developing gallstones and cholecystitis. What should the nurse instruct this patient? Select all that apply.
1. Walk for 30 minutes five times a week.
2. Eat a low-fiber, high-carbohydrate diet.
3. Eat unsaturated rather than saturated fats.
4. Eat a low-carbohydrate diet.
5. Lose weight by any means possible.
Page Ref: 815
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 25.1 Describe the pathophysiology and manifestations of gallbladder disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with gallbladder, liver, and pancreatic disorders.
25) The nurse is teaching a patient about modifiable risk factors for cholelithiasis. What risk factor will the nurse discuss? Select all that apply.
1. Age
2. Obesity
3. Alternating weight loss and gain
4. Family history
5. Elevated serum cholesterol
Page Ref: 815
Cognitive Level: Analyzing
Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning
Learning Outcome: 25.1 Describe the pathophysiology and manifestations of gallbladder disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with gallbladder, liver, and pancreatic disorders.
26) A patient scheduled for a laparoscopic cholecystectomy in 4 days asks how pain can be controlled until the surgery. How should the nurse respond?
1. "You will feel better if you sit in a recliner and drink water and try not to eat anything. Do not eat any fat."
2. "You will feel better if you rest in bed and do not eat anything until the procedure. Drink only water and milk."
3. "You will feel better if you alternate lying on your back and lying on your abdomen. You may eat anything except fatty food."
4. "You will feel better if you walk as frequently as possible. You may drink coffee, but not soda."
Page Ref: 814
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 25.1 Describe the pathophysiology and manifestations of gallbladder disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with gallbladder, liver, and pancreatic disorders.
27) The patient with acute cholelithiasis asks why a nasogastric tube has to be inserted. Which should the nurse respond?
1. "You have not been able to follow your prescribed diet and exercise plan."
2. "We need to suck the bile out through your nose as it isn't going to your duodenum."
3. "Keeping your stomach empty allows your gallbladder to rest, reducing pain."
4. "The tube will prevent pancreatitis."
Page Ref: 813
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 25.1 Describe the pathophysiology and manifestations of gallbladder disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with gallbladder, liver, and pancreatic disorders.
28) A patient with acute cholecystitis is concerned about having the flu because of an oral temperature of 101.8°F. What should the nurse respond to the patient?
1. "Your cholecystectomy cannot be performed laparoscopically now."
2. "Tell me exactly what you ate for your last meal."
3. "Bacterial infection is often present in cholelithiasis."
4. "I will call the surgeon and ask to postpone the cholecystectomy."
Page Ref: 812
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 25.1 Describe the pathophysiology and manifestations of gallbladder disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with gallbladder, liver, and pancreatic disorders.
29) The nurse is assessing the nutritional status of a patient who has cholelithiasis and a body mass index of 35. What action should the nurse take initially?
1. Ask the patient to discuss typical daily menu choices.
2. Ask the patient to discuss strategies used to manage weight.
3. Ask if the patient takes daily supplemental vitamin C.
4. Ask if the patient has been skipping meals to reduce gallbladder pain.
Page Ref: 814
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 25.1 Describe the pathophysiology and manifestations of gallbladder disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with gallbladder, liver, and pancreatic disorders.
30) A patient with an acutely inflamed gallbladder states that the pain has suddenly stopped. The patient wants to go home. What is the nurse's best response?
1. "It is your choice. You are feeling better and not required to stay."
2. "Please stay until your healthcare provider sees you tomorrow."
3. "I will inform your healthcare provider of the change in your symptoms."
4. "Yes, as soon as we perform the prescribed ultrasound of the gallbladder."
Page Ref: 814
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 25.1 Describe the pathophysiology and manifestations of gallbladder disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with gallbladder, liver, and pancreatic disorders.
31) A patient with liver failure is taking lactulose (Chronulac). Which laboratory data indicates that the medication is having the desired effect?
1. Increased serum ammonia level
2. Decreased serum ammonia level
3. Increased serum ALT level
4. Decreased serum ALT level
Page Ref: 831
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 25.2 Describe the pathophysiology and manifestations of liver disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with gallbladder, liver, and pancreatic disorders.
32) The nurse is assessing a patient with liver cirrhosis. Which findings should the nurse relate to the patient's failed liver function? Select all that apply.
1. The patient had two episodes of epistaxis.
2. The patient had toxic levels of a prescribed medication.
3. The patient is oriented to person and place but not to time.
4. The patient's urinary output has decreased.
5. The patient has cholelithiasis.
Page Ref: 836
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 25.2 Describe the pathophysiology and manifestations of liver disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with gallbladder, liver, and pancreatic disorders.
33) The nurse is teaching a patient about the effects of liver failure. Which patient statement about manifestations indicates that teaching was effective? Select all that apply.
1. "My abdomen is becoming very large."
2. "My blood sugar is sometimes too high and sometimes too low."
3. "My left lower leg is red and swollen."
4. "My menstrual cycle has become very irregular."
5. "My skin appears yellow."
Page Ref: 829
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning
Learning Outcome: 25.2 Describe the pathophysiology and manifestations of liver disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with gallbladder, liver, and pancreatic disorders.
34) The nurse is assessing a patient with liver failure and jaundice. Which question should the nurse ask to determine if the cause of the jaundice is hemolytic?
1. "Have you been diagnosed with a disorder of red blood cell destruction?"
2. "What color is your urine?"
3. "What color are your stools?"
4. "Do you have any gallbladder problems?"
Page Ref: 817
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 25.2 Describe the pathophysiology and manifestations of liver disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with gallbladder, liver, and pancreatic disorders.
35) The nurse teaches a patient about portal hypertension. Which patient statement indicates teaching was effective?
1. "In portal hypertension, blood backs up in the liver. It causes enlarged blood vessels in my esophagus."
2. "In portal hypertension, blood leaks from my liver. It causes me to feel hungry frequently."
3. "Portal hypertension means fast-spreading high blood pressure. It causes red veins on my arms."
4. "Portal hypertension means high blood pressure throughout my abdomen. It causes me to feel confused."
Page Ref: 818
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning
Learning Outcome: 25.2 Describe the pathophysiology and manifestations of liver disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with gallbladder, liver, and pancreatic disorders.
36) The patient in the icteric phase of hepatitis asks why stools are no longer brown. How should the nurse respond?
1. "Your liver isn't making any of the substance that makes stools brown."
2. "The pigment is backing up into your blood and turning your skin yellow."
3. "It is being released into your bloodstream and turning your blood darker red."
4. "The answer is not known. More research is needed regarding this question."
Page Ref: 819
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 25.2 Describe the pathophysiology and manifestations of liver disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with gallbladder, liver, and pancreatic disorders.
37) A patient who has three school-age children has jaundice and is diagnosed with hepatitis A after taking a trip to Central America. Which patient statement should the nurse address with the patient?
1. "I can't go home and expose my children to this."
2. "We cared for several very ill people on our trip."
3. "I plan to get a lot of rest in the next few days."
4. "I am likely to recover fully eventually."
Page Ref: 819
Cognitive Level: Applying
Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 25.2 Describe the pathophysiology and manifestations of liver disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with gallbladder, liver, and pancreatic disorders.
38) A patient with a distant history of injection substance use is diagnosed with hepatitis. For which type of hepatitis should the nurse plan care for this patient?
1. Hepatitis A
2. Hepatitis B
3. Hepatitis C
4. Hepatitis D
Page Ref: 819-820
Cognitive Level: Applying
Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 25.2 Describe the pathophysiology and manifestations of liver disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with gallbladder, liver, and pancreatic disorders.
39) The nurse is caring for a patient with hepatitis C who is treating the illness with licorice root. Which statement by the patient requires follow-up regarding this medication?
1. "I feel so tired all the time."
2. "My fingers feel numb and tingly."
3. "I have a dull ache in my abdomen."
4. "I have antibodies for hepatitis C in my blood."
Page Ref: 823
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 25.2 Describe the pathophysiology and manifestations of liver disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with gallbladder, liver, and pancreatic disorders.
40) The nurse is concerned that a patient with injuries from a motor vehicle crash is experiencing bleeding from liver trauma. What did the nurse assess to make this clinical determination? Select all that apply.
1. New onset of pruritus
2. New onset of lightheadedness
3. Heart rate 112 beats per minute
4. Requesting more water to drink
5. Respiratory rate 26 breaths per minute
Page Ref: 839
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 25.2 Describe the pathophysiology and manifestations of liver disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with gallbladder, liver, and pancreatic disorders.
41) A patient with chronic pancreatitis is prescribed pancrelipase (Lipancreatin). What should the nurse instruct the patient about this medication? Select all that apply.
1. Take the medication with meals or snacks.
2. Take the medication with milk or ice cream.
3. Stop taking the medication if bowel movements increase.
4. Do not crush enteric coated doses of the medication.
5. Take this medication until advised otherwise by the healthcare provider.
Page Ref: 844
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 25.3 Describe the pathophysiology and manifestations of exocrine pancreas disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with gallbladder, liver, and pancreatic disorders.
42) During a health assessment the nurse becomes concerned that a patient is at high risk for pancreatic cancer. What assessment finding caused this concern? Select all that apply.
1. The patient smokes cigarettes.
2. The patient has a body mass index of 32.5.
3. The patient has been treated for osteoarthritis.
4. The patient's uncle died from pancreatic cancer.
5. The patient has been diagnosed with chronic pancreatitis.
Page Ref: 847
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 25.3 Describe the pathophysiology and manifestations of exocrine pancreas disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with gallbladder, liver, and pancreatic disorders.
43) A patient recovering from Whipple's procedure is being transferred to the medical-surgical care area. On which intervention should the nurse focus to determine if the patient is developing a complication from the surgery? Select all that apply.
1. Assessing heart rate every 2 hours
2. Monitoring urine output every hour
3. Turning and repositioning every 2 hours
4. Measuring blood pressure every 2 hours
5. Assisting to a standing position every 4 hours
Page Ref: 847-848
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 25.3 Describe the pathophysiology and manifestations of exocrine pancreas disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with gallbladder, liver, and pancreatic disorders.
Document Information
Connected Book
Medical Surgical Nursing 7e | Test Bank by LeMone, Burke, Bauldoff
By LeMone, Burke, Gerene Bauldoff
Explore recommendations drawn directly from what you're reading
Chapter 23 GI Disorders – Nursing Care
DOCX Ch. 23
Chapter 24 Nursing Care Of Patients With Bowel Disorders
DOCX Ch. 24
Chapter 25 Gallbladder Liver Pancreas Care
DOCX Ch. 25 Current
Chapter 26 Assessing The Renal System
DOCX Ch. 26
Chapter 27 Nursing Care Of Patients With Urinary Tract Disorders
DOCX Ch. 27