A nurse is caring for a client diagnosed with acute pancreatitis. After treating the client's pain, which of the following should the nurse address as the priority intervention?
Provide oral hygiene.
Assist the client to a side-lying position.
Auscultate the client's lungs.
Withhold oral fluids and food.
The Correct Answer is D
A. Provide oral hygiene.
Providing oral hygiene is important for the client's comfort and overall well-being. However, in the context of acute pancreatitis, the immediate priority is to address the gastrointestinal symptoms and prevent further pancreatic stimulation.
B. Assist the client to a side-lying position.
Assisting the client to a side-lying position can be beneficial for comfort and may help prevent complications such as aspiration. However, it is not the immediate priority after treating the pain. Withholding oral fluids and food takes precedence in the initial management of acute pancreatitis.
C. Auscultate the client's lungs.
Auscultating the client's lungs is a routine nursing assessment and is important for respiratory monitoring. However, in the context of acute pancreatitis, the primary focus is on addressing gastrointestinal symptoms, and respiratory assessment becomes more critical if respiratory distress is suspected.
D. Withhold oral fluids and food.
Withholding oral fluids and food is the priority intervention after treating the pain in acute pancreatitis. This is done to reduce pancreatic stimulation, allowing the pancreas to rest and recover. NPO (nothing by mouth) status is often initiated in the early management of acute pancreatitis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
A. Is used to replace fluid loss.
Isotonic solutions, such as normal saline (0.9% NaCl) and lactated Ringer's solution, are used to replace fluid loss in situations such as dehydration, surgery, trauma, or other conditions where there is a need for fluid resuscitation.
B. Usually do not provide calories.
Isotonic solutions typically do not contain calories. They are designed primarily for fluid replacement and do not contribute to the nutritional needs of the patient.
C. Does not expand intravascular volume.
This statement is incorrect. Isotonic solutions are used to expand intravascular volume. When infused into the bloodstream, isotonic solutions help restore and maintain adequate blood volume. They do not cause significant shifts of fluids between compartments.
D. Mostly do not provide free water.
Isotonic solutions generally do not provide free water. They have the same osmolality as body fluids, meaning that they do not cause a net movement of water into or out of cells, and they maintain the osmotic balance.
E. Has the same osmolality as body fluids.
Isotonic solutions have the same osmolality as body fluids, which means they do not cause a net movement of water into or out of cells. This characteristic makes them suitable for situations where there is a need to expand intravascular volume without causing significant shifts in fluid compartments.
Correct Answer is C
Explanation
A. Storing unopened bottles of insulin in the freezer is incorrect. Insulin should be stored in the refrigerator, and freezing can damage the insulin.
B. Having a morning blood glucose level between 200 and 230 is too high. The target range for fasting blood glucose is generally lower, and elevated levels may indicate the need for adjustment in insulin or other medications.
C. Eating a snack half an hour before playing soccer is a correct understanding. This helps prevent hypoglycemia during physical activity. Physical activity can lower blood glucose levels, and a pre-activity snack can provide additional carbohydrates to prevent low blood sugar.
D. Not taking regular insulin when sick is incorrect. In fact, insulin needs may increase during illness, and it is usually recommended to continue taking insulin even when sick. Adjustments to the insulin regimen may be needed under the guidance of healthcare providers.
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