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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Administer a PRN dose of benzodiazepine.
Benzodiazepines can cause respiratory depression and prolong delirium, especially in clients recovering from mechanical ventilation and sedation. The client’s confusion is likely transient post-extubation delirium, which often resolves with reorientation and safety measures rather than sedation.
B. Increase the oxygen concentration to 60%.
The client is maintaining an oxygen saturation of 98% on 40% FiO₂, indicating adequate oxygenation. Increasing the oxygen concentration to 60% is unnecessary and may increase the risk of oxygen toxicity.
C. Apply bilateral wrist restraints.
The client is confused and attempting to get out of bed, increasing the risk of falls and accidental self-injury. Restraints should be used as a last resort after ensuring non-pharmacological interventions (e.g., reorientation, sitter, bed alarms) are ineffective or unavailable. If applied, restraints must be monitored closely and removed as soon as possible.
D. Notify the rapid response team.
The client’s vital signs are stable, and oxygenation is adequate. Although confusion is concerning, it does not indicate an immediate life-threatening emergency requiring a rapid response team. Instead, the nurse should implement safety interventions and continue close monitoring.

A. Turn off the pacemaker. B. Check the sensitivity control. C. Increase the milliamps (mA). D. Position the client on the left side.

Correct Answer is B

Explanation

A. Turn off the pacemaker. Turning off the pacemaker is not appropriate because the client has a third-degree heart block, which means their heart is not conducting impulses properly. Disabling the pacemaker could lead to severe bradycardia or asystole. The goal is to troubleshoot the issue rather than stopping pacing altogether.
B. Check the sensitivity control. Loss of sensing means the pacemaker is not detecting the client's intrinsic heart activity, which can lead to inappropriate pacing or failure to respond to the heart’s natural rhythm. Adjusting the sensitivity setting ensures that the pacemaker can recognize the client's heartbeats and pace appropriately. This is the first step in troubleshooting pacemaker malfunctions related to sensing issues.
C. Increase the milliamps (mA). Increasing the milliamps (mA) is used when there is failure to capture, meaning the pacemaker is delivering impulses but the heart is not responding. Since the problem here is failure to sense, adjusting the sensitivity setting is the correct first action.
D. Position the client on the left side. Repositioning the client is sometimes recommended for displacement of a transvenous pacemaker lead, but in this case, the issue is sensing failure, not lead displacement. Checking and adjusting the pacemaker settings is a more appropriate first step before considering repositioning.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

Correct Answer is B

Explanation

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