The nurse receives report for a client with acute pancreatitis on hospital day 2: NPO with NGT to low intermittent suction, VS: 110/60, 99.2°F-97- 22, 0.9% NS infusing at 125 mL/hour, and IV antibiotics have been started. Chart review reveals the following current laboratory results. Which is a priority for the nurse to report to the healthcare provider?

WBC 10,000/mm3 (5,000-10,000 mm3)

Serum potassium 3.5 mEq/L (3.5-5.0 mEq/L)

Serum albumin 4.8 g/dL (3.5-5 g/dL)

Lipase 900 u/L (20-180 u/L)

Answer and Explanation

The Correct Answer is D

A) While an elevated WBC count may indicate infection, it is not unexpected in acute pancreatitis.
B) Serum potassium within normal range does not require immediate intervention.

C) Serum albumin within normal range does not require immediate intervention.

D) Lipase levels significantly elevated above the normal range indicate ongoing pancreatic inflammation and may require intervention or adjustment of treatment.

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Correct Answer is A

Explanation

A) Chronic and excessive alcohol consumption is a well-established risk factor for the development of chronic pancreatitis.
B) While contributing to other health issues, it is not directly linked to chronic pancreatitis.

C) Smoking is a risk factor, but alcohol abuse is more significantly associated with chronic pancreatitis.
D) Although it contributes to various health problems, it is not as directly linked to chronic pancreatitis as alcohol abuse.

A. Risk for bleeding B. Risk for activity intolerance C. Risk for impaired nutrition: less than body requirements D. Risk for impaired skin integrity

Correct Answer is A

Explanation

A) Cirrhosis can lead to coagulopathy due to impaired synthesis of clotting factors by the liver, putting the client at high risk for bleeding.

B) While clients with cirrhosis may experience fatigue, it is not the priority problem indicated by the assessment data provided.
C) Decreased appetite and jaundice may affect nutritional status, but they do not pose an immediate threat compared to the risk of bleeding.
D) Jaundice can lead to pruritus and increased risk of skin breakdown, but it is not the priority problem indicated by the assessment data provided.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When reviewing a client's health history, which information does the nurse identify as a risk factor for development of chronic pancreatitis?

Correct Answer is A

Explanation

A client with cirrhosis has the following current assessment data: jaundice, decreased appetite, hemoglobin 15 g/dL (14-18 g/dL) and PT of 20.6 seconds (11-12.5 sec). What does the nurse identify as the priority problem for this client?

Correct Answer is A

Explanation

The nurse is admitting a client with liver disease who presents with dyspnea, weight gain and abdominal distention. Which order would the nurse anticipate?

When planning care for a client receiving an enteral feeding via jejunostomy tube, which intervention would the nurse include?

A client with cirrhosis is scheduled to receive a third dose of lactulose (Cephulac) at 1800. Which current finding would cause the nurse to question administering this medication?

The client with cirrhosis is at risk for developing complications. Which condition is the most serious and potentially life-threatening?

The nurse is collecting a health history of a client admitted for possible acute pancreatitis. Which health history item would increase the client's risk for this diagnosis?

The nurse is caring for a client with chronic pancreatitis who exhibits signs of malabsorption. The nurse recognizes that this is due to which pathophysiology process?

The nurse is preparing a client presentation regarding pancrelipase (Viokase) therapy. Which information would the nurse include in the teaching session?

The nurse is preparing to administer spironolactone (Aldactone) and furosemide (Lasix) at 0900 to a client diagnosed with ascites. Review of 0600 laboratory results shows serum sodium 130 mEq/L (136-145 mEq/L) and potassium 3.1 mEq/L (3.5-5.0 mEq/L). Which action should the nurse take first?