A client is admitted to the medical unit with acute pancreatitis. While planning care for this client, the nurse will include which of the following interventions? (Select all that apply).
Administer antiemetics as needed.
Administer analgesics as needed.
NPO (nothing by mouth) until pain-free.
Monitor blood glucose and provide insulin as needed.
Side-lying or fetal position.
Monitor hydration status.
Correct Answer : A,B,C,D,F
Choice A: Administer antiemetics as needed Reason: Acute pancreatitis often causes severe nausea and vomiting. Antiemetics are administered to control these symptoms and prevent further complications such as dehydration and electrolyte imbalance.
Choice B: Administer analgesics as needed Reason: Pain management is a crucial part of the treatment for acute pancreatitis. The condition can cause severe abdominal pain, and analgesics are administered to provide relief.
Choice C: NPO (nothing by mouth) until pain-free Reason: The goal in treating acute pancreatitis is to allow the pancreas to rest and recover from the inflammation3. Keeping the patient NPO (nothing by mouth) helps achieve this by reducing the stimulation and workload of the pancreas.
Choice D: Monitor blood glucose and provide insulin as needed Reason: Acute pancreatitis can affect the pancreas’ ability to produce insulin, leading to elevated blood glucose levels. Therefore, monitoring blood glucose levels and administering insulin as needed is an important part of the management plan.
Choice E: Side-lying or fetal position Reason: While the side-lying or fetal position might help some patients with abdominal pain, it is not a standard intervention for acute pancreatitis. Therefore, this option is not correct.
Choice F: Monitor hydration status Reason: Patients with acute pancreatitis are at risk of dehydration due to symptoms like vomiting and decreased oral intake. Monitoring hydration status is crucial to ensure appropriate fluid replacement.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E","F"]
Explanation
Choice A: Shortness of breath Shortness of breath can occur with a TAA due to the aneurysm compressing the trachea or the lung tissue. As the aneurysm enlarges, it can impinge on respiratory structures, leading to difficulty in breathing. A thoracic aortic aneurysm (TAA) is a bulging or dilation in the wall of the aorta as it passes through the chest cavity. TAAs can be life-threatening if they rupture or dissect and are often difficult to detect because they tend to grow slowly and usually do not cause symptoms until they become large or rupture.
Choice B: Difficulty swallowing Difficulty swallowing, or dysphagia, may be experienced if a TAA exerts pressure on the esophagus. This can happen when the aneurysm is located in the aortic arch, where the esophagus is in close proximity.
Choice C: Upper chest pain Upper chest pain is a common symptom of TAA and may be described as a deep, steady pain that can radiate to the back, neck, or jaw. The pain is caused by the stretching of the aortic wall and may be a warning sign of an impending rupture.
Choice D: Diaphoresis Diaphoresis, or excessive sweating, is not typically a direct symptom of a TAA. However, it can be associated with acute aortic syndromes, such as aortic dissection or rupture, which are medical emergencies.
Choice E: Cough A persistent cough can be a sign of a TAA, especially if the aneurysm is pressing against the trachea or bronchial tubes. The cough may sometimes produce blood if the aneurysm is causing erosion into these structures.
Choice F: Hoarseness Hoarseness can result from a TAA if the aneurysm compresses the recurrent laryngeal nerve, which controls the muscles of the voice box. This is known as Ortner’s syndrome or cardiovocal syndrome.
Correct Answer is ["167"]
Explanation
- Step 1: Identify the client's weight in pounds. The client weighs 245 lbs.
- Step 2: Convert the client's weight from pounds to kilograms. We know that 1 kg = 2.2 lbs. So, 245 lbs = 245 ÷ 2.2 kg. Calculating the division gives us approximately 111.36 kg.
- Step 3: Identify the prescribed dose in mg/kg. The client is scheduled to receive 1.5 mg/kg of enoxaparin.
- Step 4: Calculate the total dose in mg. We can do this by multiplying the client's weight in kg by the prescribed dose in mg/kg:
- Total dose = 1.5 mg/kg × 111.36 kg.
- Calculating the multiplication gives us approximately 167.04 mg.
- Step 5: Round the total dose to the nearest whole number. Rounding 167.04 gives us 167.
administer 167 mg of enoxaparin per dose.
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