A client diagnosed with pancreatitis reports severe epigastric pain. After administering a narcotic analgesic, the client insists on Tip sitting up and leaning forward. Which action should the nurse implement?
Provide a bedside table for client to lean across.
Place bed in the reverse Trendelenburg position.
Encourage bed rest until analgesic takes effect.
Raise the head of the bed to a 90 degree angle.
The Correct Answer is A
A. Provide a bedside table for the client to lean across. Clients with acute pancreatitis often experience severe epigastric pain that radiates to the back. Leaning forward helps reduce pressure on the inflamed pancreas and relieves pain by minimizing peritoneal irritation. Providing a bedside table allows the client to rest in a comfortable, supported position, improving pain management without additional interventions.
B. Place bed in the reverse Trendelenburg position. Reverse Trendelenburg elevates the head and lowers the feet, which does not specifically relieve pain associated with pancreatitis. The client instinctively leans forward for relief, and adjusting the bed position would not provide the same benefit. This intervention does not directly address the underlying cause of discomfort.
C. Encourage bed rest until analgesic takes effect. Although pain control is essential, keeping the client in a supine or bedrest position can increase abdominal pressure and worsen discomfort. Allowing the client to assume a comfortable position enhances the effectiveness of analgesics and prevents unnecessary distress. Pain relief strategies should focus on both pharmacologic and positioning interventions.
D. Raise the head of the bed to a 90-degree angle. Elevating the head of the bed can improve breathing and reduce reflux, but it does not provide the same pressure relief as leaning forward. Sitting upright without forward support does not effectively relieve peritoneal irritation from pancreatic inflammation. Providing a bedside table supports proper positioning and enhances comfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Administer a PRN bolus normal saline. The client is exhibiting signs of hypovolemic shock, including tachycardia (HR 110 bpm), tachypnea (RR 24), and hypotension (BP 80/50 mmHg) following massive gastrointestinal bleeding and multiple blood transfusions. Immediate fluid resuscitation with a normal saline bolus is the priority to restore intravascular volume, maintain perfusion, and prevent further deterioration.
B. Obtain a blood specimen for hematocrit. While monitoring hematocrit is important to assess ongoing blood loss, it does not take priority over treating the client’s current hypovolemia. A delay in resuscitation could worsen hypotension, decrease organ perfusion, and lead to shock.
C. Measure strict hourly urinary output. Monitoring urine output is important in assessing renal perfusion and fluid balance, but the client’s immediate need is volume replacement. If fluid resuscitation is delayed, renal perfusion could worsen, leading to acute kidney injury.
D. Switch oxygen delivery to a face mask. The client’s oxygen saturation is 94% on 4 L/min nasal cannula, indicating adequate oxygenation at this time. Increasing oxygen delivery is not immediately necessary compared to fluid resuscitation. However, if the client’s condition worsens, oxygen therapy adjustments may be needed.
Correct Answer is D
Explanation
A. Heparin is infused in less than four hours. The heparinized solution used in an intra-arterial (IA) pressure infuser is not intended for systemic anticoagulation but rather to maintain catheter patency. The infusion rate is typically slow and continuous, and completing the infusion in less than four hours is not an indicator of effectiveness.
B. Systolic blood pressure greater than 120 mm Hg. Heparin in an IA pressure infuser does not directly affect blood pressure. Its purpose is to prevent clot formation within the catheter, ensuring uninterrupted arterial pressure monitoring. BP readings are monitored separately and are not an indicator of heparin’s therapeutic effect.
C. No knee pain upon forced dorsiflexion. This assessment is used to evaluate deep vein thrombosis (DVT) (Homan's sign), which is not related to arterial catheter function. The low-dose heparin in the pressure infuser does not provide systemic anticoagulation, making this finding irrelevant.
D. Intra-arterial cannula remains patent. The primary purpose of heparinized flush solutions in IA lines is to prevent clot formation within the catheter and maintain patency for continuous blood pressure monitoring or arterial blood sampling. A patent arterial line confirms that the heparin infusion is achieving its intended effect.
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