A client with acute pancreatitis has the following assessment: abdominal pain 7/10, nausea and vomiting for 2 days, vital signs: BP 108/70 mmHg, temperature 99.8°F, pulse 98 bpm, respiratory rate 22 breaths/min, inelastic skin turgor, and concentrated urine. Which nursing diagnosis should the nurse select as a priority?
Impaired elimination.
Fluid imbalance.
Fever.
Nausea.
The Correct Answer is B
Choice A reason: Impaired elimination may be a concern with pancreatitis due to potential complications affecting the gastrointestinal tract, but it is not the immediate priority.
Choice B reason: Fluid imbalance is the most critical issue in acute pancreatitis, as evidenced by inelastic skin turgor and concentrated urine, indicating dehydration, which can exacerbate the condition and lead to hypovolemic shock.
Choice C reason: Fever may be present due to inflammation or infection, but the temperature provided is not indicative of a significant fever and is not the priority over fluid imbalance.
Choice D reason: Nausea is a symptom of acute pancreatitis and while it needs to be managed, it is not the priority over fluid imbalance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Encouraging ambulation is not a priority during a thyroid storm, as it can exacerbate symptoms.
Choice B reason: Sending a urine sample for culture is not related to the immediate management of thyroid storm.
Choice C reason: Monitoring temperature is crucial in the management of thyroid storm, as hyperthermia is a common and serious symptom.
Choice D reason: Administering levothyroxine during a thyroid storm would be contraindicated, as it could worsen the condition.
Correct Answer is B
Explanation
Choice A reason: Monitoring heart rate and rhythm is important in heart failure management, but it does not directly reflect the effectiveness of enalapril and furosemide, which are primarily used to control blood pressure and reduce fluid overload, respectively.
Choice B reason: Auscultating lung fields can reveal the presence of fluid, indicating pulmonary edema, a common complication of left-sided heart failure. Checking BP is essential as enalapril is an ACE inhibitor that lowers BP, and furosemide can also affect BP through its diuretic effect.
Choice C reason: Assessing for JVD can indicate right-sided heart failure, which may develop secondary to left-sided heart failure. However, it is not the primary assessment for the effectiveness of enalapril and furosemide.
Choice D reason: Checking peripheral pulses is a general assessment and, while important, it does not specifically evaluate the effectiveness of the medications in question.
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