a client with pancreatitis has been transferred to the intensive care unit which order would the nurse anticipate

NCLEX-PN

Nclex 2024 Questions

1. A client with pancreatitis has been transferred to the intensive care unit. Which order would the nurse anticipate?

A. Blood pressure monitoring every 15 minutes
B. Insertion of a Levine tube
C. Continuous cardiac monitoring
D. Administration of pain medication every 4 hours

Correct answer: B

Rationale: In a client with pancreatitis who frequently experiences nausea and vomiting, insertion of a Levine tube is often anticipated to decompress the stomach and rest the bowel, helping to alleviate symptoms. This intervention is crucial in managing the gastrointestinal symptoms associated with pancreatitis. Blood pressure monitoring every 15 minutes may be necessary in some cases, but it is not a routine order for pancreatitis, making option A less likely. Continuous cardiac monitoring could be required based on the individual's condition, but it is not typically the first priority in pancreatitis management, so option C is not the most anticipated order. While pain medication administration is essential for managing discomfort, the priority in this scenario, especially considering the symptoms of nausea and vomiting, would be decompression with a Levine tube to address gastrointestinal issues, making option D less likely.

2. In the context of milieu therapy, what is its primary purpose?

A. exploring the client's perception of reality
B. enhancing social interaction abilities
C. addressing maladaptive behaviors
D. providing routine daily experiences

Correct answer: D

Rationale: Milieu therapy aims to provide routine daily experiences to clients. By offering a structured and predictable environment, it helps individuals feel safe and secure, reducing disruptive behaviors. Exploring the client's perception of reality (choice A) may be part of therapy but not the primary focus. Enhancing social interaction abilities (choice B) and addressing maladaptive behaviors (choice C) are important aspects of therapy but not the primary purpose of milieu therapy.

3. When a staff member is observed not following the plan of care for a client with an antisocial personality disorder, what should the nurse do?

A. confront the staff member immediately and say, "You know that is not the treatment plan."?
B. write an incident report to create a paper trail of the staff member's failure to follow the planned program.
C. ask the staff member to talk in private, and reinforce how antisocial clients try to divide staff.
D. bring up the incident during the weekly conference so that this staff member is not assigned to work with antisocial persons again.

Correct answer: C

Rationale: When a staff member is observed not following the plan of care for a client with an antisocial personality disorder, it is crucial to address the issue promptly and effectively. Confronting the staff member immediately in front of the client may worsen the situation by enhancing the division of staff and compromising client care. Writing an incident report, although important for documentation, may not address the immediate need to correct the behavior. Bringing up the incident during a weekly conference may not be the most effective approach for immediate resolution. Asking the staff member to talk in private and reinforcing how antisocial clients try to divide staff is the best option. This approach allows for a constructive conversation to address the issue, provide education, and help the staff member develop skills to work effectively with this client population.

4. If the client is receiving peritoneal dialysis and the dialysate returns cloudy, what should the nurse do?

A. Document the finding
B. Send a specimen to the lab
C. Strain the dialysate
D. Obtain a complete blood count

Correct answer: B

Rationale: When the dialysate returns cloudy, it could indicate the presence of infection, and sending a specimen to the lab for evaluation is crucial to determine the cause. Documenting the finding alone, as in choice A, may not provide enough information for proper intervention. Straining the dialysate, as in choice C, is not a standard practice and may not help identify the underlying issue. Obtaining a complete blood count, as in choice D, is not directly related to addressing cloudiness in the dialysate. However, the healthcare provider might order a white blood cell count to assess for infection.

5. Who may legally give informed consent?

A. an 86-year-old male with advanced Alzheimer's disease
B. a 14-year-old girl needing an appendectomy who is not an emancipated minor
C. a 14-year-old girl needing an appendectomy who is not an emancipated minor
D. a 6-month-old baby needing bowel surgery

Correct answer: C

Rationale: The correct answer is a 14-year-old girl needing an appendectomy who is not an emancipated minor. Informed consent can be given by individuals who are competent and not minors. Minors are generally unable to provide informed consent unless they are emancipated. Choice A is incorrect because an 86-year-old male with advanced Alzheimer's disease is considered incompetent to make decisions. Choice D is incorrect because a 6-month-old baby is unable to provide consent. Emancipated minors are an exception to the minor rule, as they can provide consent for their own treatment.