the client diagnosed with acute pancreatitis has developed a pseudocyst that ruptures which procedure should the nurse anticipate the hcp ordering

ATI RN

ATI RN Custom Exams Set 2

1. A client diagnosed with acute pancreatitis has developed a pseudocyst that ruptures. Which procedure should the nurse anticipate the healthcare provider ordering?

A. Paracentesis
B. Chest tube insertion
C. Lumbar puncture
D. Biopsy of the pancreas

Correct answer: B

Rationale: The correct answer is B: Chest tube insertion. A chest tube may be needed if a pancreatic pseudocyst ruptures into the pleural space, causing a pleural effusion. Paracentesis (choice A) involves the removal of fluid from the abdominal cavity, not typically indicated for a pancreatic pseudocyst. Lumbar puncture (choice C) is a procedure to collect cerebrospinal fluid from the spinal canal, not relevant to a pancreatic pseudocyst. Biopsy of the pancreas (choice D) is a diagnostic procedure to obtain tissue samples for examination and is not typically done in the context of a ruptured pseudocyst.

2. The nurse is caring for clients on a cardiac floor. Which client should the nurse assess first?

A. The client with three (3) unifocal PVCs in a minute
B. The client diagnosed with coronary artery disease who wants to ambulate
C. The client diagnosed with mitral valve prolapse with an audible S3
D. The client diagnosed with pericarditis who is in normal sinus rhythm

Correct answer: C

Rationale: The correct answer is C because an audible S3 in a client with mitral valve prolapse could indicate heart failure and requires immediate assessment. Choice A is not as urgent as an audible S3 in mitral valve prolapse. Choice B, a client with coronary artery disease wanting to ambulate, does not present an immediate concern compared to a potential heart failure indicated by an audible S3. Choice D, a client with pericarditis in normal sinus rhythm, is stable and does not require immediate attention when compared to a potential heart failure situation signified by an audible S3 in mitral valve prolapse.

3. The nurse is teaching a community class to people with Type 2 diabetes mellitus. Which explanation would explain the development of Type 2 diabetes?

A. The islet cells in the pancreas stop producing insulin
B. The client eats too many foods that are high in sugar
C. The pituitary gland does not produce vasopressin
D. The cells become resistant to the circulating insulin

Correct answer: D

Rationale: The correct answer is D. In Type 2 diabetes, the primary issue is insulin resistance, where cells do not respond effectively to insulin. Choice A is incorrect because in Type 1 diabetes, the islet cells in the pancreas stop producing insulin. Choice B is not directly related to the development of Type 2 diabetes but rather to its management. Choice C is incorrect as it refers to a dysfunction in vasopressin production, which is not related to Type 2 diabetes.

4. Enteral feedings may be appropriate for patients with:

A. Acute cholecystitis
B. Hepatic encephalopathy
C. Ulcerative colitis in remission
D. Acute exacerbation of Crohn’s disease

Correct answer: D

Rationale: Enteral feedings are commonly utilized for patients experiencing acute exacerbations of Crohn’s disease to provide necessary nutrition and rest the bowel. Choices A, B, and C are incorrect because enteral feedings are not typically indicated for acute cholecystitis, hepatic encephalopathy, or ulcerative colitis in remission.

5. Where do most peptic ulcers occur?

A. Esophagus
B. Stomach
C. Duodenum
D. Jejunum

Correct answer: C

Rationale: Most peptic ulcers occur in the duodenum, particularly in cases of duodenal ulcers. The correct answer is the duodenum because it is the most common site for peptic ulcers to develop. Peptic ulcers rarely occur in the esophagus and jejunum, making choices A, B, and D incorrect.