RNSG 2539 EXAM 2 QUESTIONS AND
ANSWERS ALL CORRECT
A home health nurse is caring for a patient discharged home after pancreatic surgery.
The nurse documents the nursing diagnosis Risk for Imbalanced Nutrition: Less than
Body Requirements on the care plan based on the potential complications that may
occur after surgery. What are the most likely complications for the patient who has had
pancreatic surgery?
A) Proteinuria and hyperkalemia
B) Hemorrhage and hypercalcemia
C) Weight loss and hypoglycemia
D) Malabsorption and hyperglycemia - Answer- D) Malabsorption and hyperglycemia
A patient has been treated in the hospital for an episode of acute pancreatitis. The
patient has acknowledged the role that his alcohol use played in the development of his
health problem but has not expressed specific plans for lifestyle changes after
discharge. What is the nurse's most appropriate response?
A) Educate the patient about the link between alcohol use and pancreatitis.
B) Ensure that the patient knows the importance of attending follow-up appointments.
C) Refer the patient to social work or spiritual care.
D) Encourage the patient to connect with a community-based support group - Answer-
D) Encourage the patient to connect with a community-based support group
A patient is being treated on the acute medical unit for acute pancreatitis. The nurse has
identified a diagnosis of Ineffective Breathing Pattern Related to Pain. What intervention
should the nurse perform in order to best address this diagnosis?
A) Position the patient supine to facilitate diaphragm movement.
B) Administer corticosteroids by nebulizer as ordered.
C) Perform oral suctioning as needed to remove secretions.
D) Maintain the patient in a semi-Fowler's position whenever possible. - Answer- D)
Maintain the patient in a semi-Fowler's position whenever possible.
A nurse is creating a care plan for a patient with acute pancreatitis. The care plan
includes reduced activity. What rationale for this intervention should be cited in the care
plan?
A) Bed rest reduces the patient's metabolism and reduces the risk of metabolic acidosis.
B) Reduced activity protects the physical integrity of pancreatic cells.
,C) Bed rest lowers the metabolic rate and reduces enzyme production.
D) Inactivity reduces caloric need and gastrointestinal motility. - Answer- C) Bed rest
lowers the metabolic rate and reduces enzyme production.
An adult patient has been admitted to the medical unit for the treatment of acute
pancreatitis. What nursing action should be included in this patient's plan of care?
A) Measure the patient's abdominal girth daily.
B) Limit the use of opioid analgesics.
C) Monitor the patient for signs of dysphagia.
D) Encourage activity as tolerated. - Answer- A) Measure the patient's abdominal girth
daily.
What are the manifestations of neurogenic shock? - Answer- Vasodilation occurs as a
result of a loss of balance between parasympathetic and sympathetic stimulation.
If prevention measures fail, treatment measures to reverse MODS are: - Answer-
controlling the initiating event, promoting adequate organ perfusion, providing nutritional
support, and maximizing patient comfort.
Because of the lack of physiologic reserve and natural degenerative process, especially
immune compromise, who is at the most risk for MODS? - Answer- older patients
If fluid rescucitation is not achieved to restore BP and CO, what vasopressors are used
in order? - Answer- Norepineohrine/phenylephrine, epinephrine, vasopressin.
What class of medications would you avoid to administer if the patient is in septic
shock? - Answer- Neuromuscular blockade agents such as acetocholine.
What level would glucose need to be at before administrating IV insulin therapy for a
patient in septic shock? - Answer- 180mg/dL
Because of sepsis, what blood product is administered if the Hgb is <7g/dL? - Answer-
pRBC
How much urine output is needed to achieve blood pressure support? - Answer-
>0.5mL/kg/h
What are the assessment paramaters for reassessing intravascular volume status and
tissue perfusion for sepsis? - Answer- Measure CVP (goal 8-12mmHg), Measure Scv
O2 (goal >70%), bedside cardiovascular ultrasound, dynamic assessment of fluid
responsiveness with passive leg raise or fluid challenge.
What are some examples of the pathophysiology of MODS? - Answer- Uncontrolled
inflammatory response, activation of inflammatory cells, release of mediators, damage
to endothelium, hypermetabolism, vasodilation, decreasing of SVR and hypotension
,occurs, increase in vascular permeability, protein and mediators leak to interstitial
space, WBC's begin to digest foreign debris, coagulation cascade is activated,
hypotension, decreased perfusion, micro emboli and shunting of: respiratory system,
renal system, cardiovascular system, neurologic system, hematologic system.
The ICU nurse is caring for a patient with MODS due to shock. What nursing action
should be prioritized at this point during care? - Answer- Providing information and
support to family members.
What lab testing results are indicative of DIC? - Answer- -Prothrombin Time (PT)
-partial throboplastin time (PTT)
-Activated Partial Thrompoplastin Time (aPTT)
-Bleeding Time
-Thrombin Time
Decrease levels: -Fibrogen
-Platelets
-Clotine factor II, V, VIII, & X
and Antithrombin III
The nurse is reviewing the laboratory test results of a child diagnosed with disseminated
intravascular coagulation (DIC). Which of the following would the nurse interpret as
indicative of this disorder?
A) Shortened prothrombin time
B) Increased fibrinogen level
C) Positive fibrin split products
D) Increased platelets - Answer- C) Positive fibrin split products
The nurse is caring for a postpartum patient admitted to the intensive care unit with a
diagnosis of disseminated intravascular coagulation (DIC). What is the drug of choice to
treat this problem?
A. Heparin
B. Urokinase
C. Aspirin
D. Warfarin - Answer- A.) Heparin
In the ICU, a postsurgical client has developed sepsis and is being treated with multiple
medications. During the mid-morning assessment, which finding leads the nurse to
suspect the client may be developing a complication called disseminated intravascular
coagulation (DIC)? Select all that apply.
A) Headaches associated with light sensitivity
B) Oozing from all previous puncture and intravenous sites
, C) Decreased O2 saturation and diminished breath sounds in lower lobes
D) Hemorrhage from the surgical site requiring deep pressure dressings
E) Urine from the Foley catheter is bloody - Answer- D) Hemorrhage from the surgical
site requiring deep pressure dressings
A healthy, primiparous (first-time) mother delivered a healthy infant several hours ago,
but the mother has experienced postpartum hemorrhage. Which of the following
disorders is most likely to underlie the client's excessive bleeding after delivery?
A) Disseminated intravascular coagulation
B) Hemophilia A
C) Von Willebrand disease
D) Thrombotic thrombocytopenic purpura (TTP) - Answer- A) Disseminated
intravascular coagulation
What is the concept behind heparin for PT with DIC? - Answer- -It prevents the clotting
phase from being completed which inhibits the breakdown of fibrinogen.
- It also helps avoid hemorrhage by preventing the body from depleting entire stage of
coagulation factors.
What are some acute clinical manifestations of DIC? - Answer- -Directly related to
bleeding problems such as:
Petechia, Purpura, oozing from puncture sites or severe hemorrhaging.
How does DIC happen in postpartum hemorrhaging? - Answer- -Tissue factors released
from necrotic place/fetal tissue or amniotic fluid my enter the circulation, inciting DIC.
What is a common cause of DIC? - Answer- -Sepsis
A patient with DIC is at a higher risk for what? - Answer- -Deficient fluid volume
Increased levels of ____________, _______________, __________, and
________________ will be noted in DIC: - Answer- -Fibrinolycin, fibrinopeptide A,
positive fibrin split products and D-dimers.
DIC can occur secondary to what type of conditions? Select all that apply: - Answer- -
Abrupitoplacente
-Amniotic fluid embolism
-Endotoxin sepsis
-Retained dead fetus
-Post hemorrhage shock
-Hydatidformmole
-Gynecologic Malinganries
DIC can be decreased as a loss of balance between what two activities? - Answer- -Clot
forming activity of thrombin
ANSWERS ALL CORRECT
A home health nurse is caring for a patient discharged home after pancreatic surgery.
The nurse documents the nursing diagnosis Risk for Imbalanced Nutrition: Less than
Body Requirements on the care plan based on the potential complications that may
occur after surgery. What are the most likely complications for the patient who has had
pancreatic surgery?
A) Proteinuria and hyperkalemia
B) Hemorrhage and hypercalcemia
C) Weight loss and hypoglycemia
D) Malabsorption and hyperglycemia - Answer- D) Malabsorption and hyperglycemia
A patient has been treated in the hospital for an episode of acute pancreatitis. The
patient has acknowledged the role that his alcohol use played in the development of his
health problem but has not expressed specific plans for lifestyle changes after
discharge. What is the nurse's most appropriate response?
A) Educate the patient about the link between alcohol use and pancreatitis.
B) Ensure that the patient knows the importance of attending follow-up appointments.
C) Refer the patient to social work or spiritual care.
D) Encourage the patient to connect with a community-based support group - Answer-
D) Encourage the patient to connect with a community-based support group
A patient is being treated on the acute medical unit for acute pancreatitis. The nurse has
identified a diagnosis of Ineffective Breathing Pattern Related to Pain. What intervention
should the nurse perform in order to best address this diagnosis?
A) Position the patient supine to facilitate diaphragm movement.
B) Administer corticosteroids by nebulizer as ordered.
C) Perform oral suctioning as needed to remove secretions.
D) Maintain the patient in a semi-Fowler's position whenever possible. - Answer- D)
Maintain the patient in a semi-Fowler's position whenever possible.
A nurse is creating a care plan for a patient with acute pancreatitis. The care plan
includes reduced activity. What rationale for this intervention should be cited in the care
plan?
A) Bed rest reduces the patient's metabolism and reduces the risk of metabolic acidosis.
B) Reduced activity protects the physical integrity of pancreatic cells.
,C) Bed rest lowers the metabolic rate and reduces enzyme production.
D) Inactivity reduces caloric need and gastrointestinal motility. - Answer- C) Bed rest
lowers the metabolic rate and reduces enzyme production.
An adult patient has been admitted to the medical unit for the treatment of acute
pancreatitis. What nursing action should be included in this patient's plan of care?
A) Measure the patient's abdominal girth daily.
B) Limit the use of opioid analgesics.
C) Monitor the patient for signs of dysphagia.
D) Encourage activity as tolerated. - Answer- A) Measure the patient's abdominal girth
daily.
What are the manifestations of neurogenic shock? - Answer- Vasodilation occurs as a
result of a loss of balance between parasympathetic and sympathetic stimulation.
If prevention measures fail, treatment measures to reverse MODS are: - Answer-
controlling the initiating event, promoting adequate organ perfusion, providing nutritional
support, and maximizing patient comfort.
Because of the lack of physiologic reserve and natural degenerative process, especially
immune compromise, who is at the most risk for MODS? - Answer- older patients
If fluid rescucitation is not achieved to restore BP and CO, what vasopressors are used
in order? - Answer- Norepineohrine/phenylephrine, epinephrine, vasopressin.
What class of medications would you avoid to administer if the patient is in septic
shock? - Answer- Neuromuscular blockade agents such as acetocholine.
What level would glucose need to be at before administrating IV insulin therapy for a
patient in septic shock? - Answer- 180mg/dL
Because of sepsis, what blood product is administered if the Hgb is <7g/dL? - Answer-
pRBC
How much urine output is needed to achieve blood pressure support? - Answer-
>0.5mL/kg/h
What are the assessment paramaters for reassessing intravascular volume status and
tissue perfusion for sepsis? - Answer- Measure CVP (goal 8-12mmHg), Measure Scv
O2 (goal >70%), bedside cardiovascular ultrasound, dynamic assessment of fluid
responsiveness with passive leg raise or fluid challenge.
What are some examples of the pathophysiology of MODS? - Answer- Uncontrolled
inflammatory response, activation of inflammatory cells, release of mediators, damage
to endothelium, hypermetabolism, vasodilation, decreasing of SVR and hypotension
,occurs, increase in vascular permeability, protein and mediators leak to interstitial
space, WBC's begin to digest foreign debris, coagulation cascade is activated,
hypotension, decreased perfusion, micro emboli and shunting of: respiratory system,
renal system, cardiovascular system, neurologic system, hematologic system.
The ICU nurse is caring for a patient with MODS due to shock. What nursing action
should be prioritized at this point during care? - Answer- Providing information and
support to family members.
What lab testing results are indicative of DIC? - Answer- -Prothrombin Time (PT)
-partial throboplastin time (PTT)
-Activated Partial Thrompoplastin Time (aPTT)
-Bleeding Time
-Thrombin Time
Decrease levels: -Fibrogen
-Platelets
-Clotine factor II, V, VIII, & X
and Antithrombin III
The nurse is reviewing the laboratory test results of a child diagnosed with disseminated
intravascular coagulation (DIC). Which of the following would the nurse interpret as
indicative of this disorder?
A) Shortened prothrombin time
B) Increased fibrinogen level
C) Positive fibrin split products
D) Increased platelets - Answer- C) Positive fibrin split products
The nurse is caring for a postpartum patient admitted to the intensive care unit with a
diagnosis of disseminated intravascular coagulation (DIC). What is the drug of choice to
treat this problem?
A. Heparin
B. Urokinase
C. Aspirin
D. Warfarin - Answer- A.) Heparin
In the ICU, a postsurgical client has developed sepsis and is being treated with multiple
medications. During the mid-morning assessment, which finding leads the nurse to
suspect the client may be developing a complication called disseminated intravascular
coagulation (DIC)? Select all that apply.
A) Headaches associated with light sensitivity
B) Oozing from all previous puncture and intravenous sites
, C) Decreased O2 saturation and diminished breath sounds in lower lobes
D) Hemorrhage from the surgical site requiring deep pressure dressings
E) Urine from the Foley catheter is bloody - Answer- D) Hemorrhage from the surgical
site requiring deep pressure dressings
A healthy, primiparous (first-time) mother delivered a healthy infant several hours ago,
but the mother has experienced postpartum hemorrhage. Which of the following
disorders is most likely to underlie the client's excessive bleeding after delivery?
A) Disseminated intravascular coagulation
B) Hemophilia A
C) Von Willebrand disease
D) Thrombotic thrombocytopenic purpura (TTP) - Answer- A) Disseminated
intravascular coagulation
What is the concept behind heparin for PT with DIC? - Answer- -It prevents the clotting
phase from being completed which inhibits the breakdown of fibrinogen.
- It also helps avoid hemorrhage by preventing the body from depleting entire stage of
coagulation factors.
What are some acute clinical manifestations of DIC? - Answer- -Directly related to
bleeding problems such as:
Petechia, Purpura, oozing from puncture sites or severe hemorrhaging.
How does DIC happen in postpartum hemorrhaging? - Answer- -Tissue factors released
from necrotic place/fetal tissue or amniotic fluid my enter the circulation, inciting DIC.
What is a common cause of DIC? - Answer- -Sepsis
A patient with DIC is at a higher risk for what? - Answer- -Deficient fluid volume
Increased levels of ____________, _______________, __________, and
________________ will be noted in DIC: - Answer- -Fibrinolycin, fibrinopeptide A,
positive fibrin split products and D-dimers.
DIC can occur secondary to what type of conditions? Select all that apply: - Answer- -
Abrupitoplacente
-Amniotic fluid embolism
-Endotoxin sepsis
-Retained dead fetus
-Post hemorrhage shock
-Hydatidformmole
-Gynecologic Malinganries
DIC can be decreased as a loss of balance between what two activities? - Answer- -Clot
forming activity of thrombin
