A nurse is caring for a client who has acute pancreatitis. After treating the client’s pain, which of the following should the nurse address as the priority intervention?
Withhold oral fluids and food.
Auscultate the client’s lungs.
Provide oral hygiene.
Assist the client to a side-lying position.
The Correct Answer is A
Choice A reason: Withhold oral fluids and food
Withholding oral fluids and food (NPO status) is a critical intervention for clients with acute pancreatitis. This helps to rest the pancreas by reducing the stimulation of pancreatic enzyme secretion, which can exacerbate inflammation and pain. Maintaining NPO status is essential to prevent further pancreatic damage and to allow the pancreas to heal.
Choice B reason: Auscultate the client’s lungs
While auscultating the lungs is an important part of the overall assessment, it is not the immediate priority after pain management in acute pancreatitis. Respiratory complications can occur, but the primary focus should be on managing the pancreatic inflammation and preventing further damage.
Choice C reason: Provide oral hygiene
Providing oral hygiene is important for overall patient care, especially when the client is NPO. However, it is not the priority intervention immediately after pain management. The primary concern is to prevent further pancreatic stimulation and manage the inflammation.
Choice D reason: Assist the client to a side-lying position
Assisting the client to a side-lying position can help with comfort and may be beneficial in managing pain. However, it is not the priority intervention. The main focus should be on preventing further pancreatic stimulation by withholding oral intake.
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Correct Answer is B
Explanation
Choice A reason: Discussing the visitation policy is important for the client’s overall hospital experience but does not directly relate to the prevention of postoperative complications. Visitation policies help manage the flow of visitors and ensure the client gets adequate rest, but they do not address specific postoperative risks.
Choice B reason: Instructing the client about the use of a sequential compression device is crucial for preventing deep vein thrombosis (DVT) and pulmonary embolism, which are common postoperative complications. Sequential compression devices (SCDs) help improve blood circulation in the legs, reducing the risk of blood clots forming during periods of immobility after surgery.
Choice C reason: Teaching the client how to use the PCA pump (patient-controlled analgesia) is important for pain management but does not directly prevent postoperative complications. Proper pain management can aid in recovery by allowing the client to move and breathe more effectively, but it is not a primary preventive measure for complications like DVT or infections.
Choice D reason: Reviewing the pain scale helps the client communicate their pain levels effectively, which is important for managing postoperative pain. However, like the PCA pump, it does not directly prevent complications. Effective pain management can contribute to overall recovery but is not a standalone preventive measure.
Correct Answer is D
Explanation
Choice A reason: Placing the shoulder harness straps below the level of the newborn’s armpits is incorrect. The shoulder harness straps should be at or below the level of the newborn’s shoulders to ensure a snug and secure fit.
Choice B reason: Keeping the car seat rear-facing until the newborn can sit unsupported is incorrect. The car seat should remain rear-facing until the child reaches the maximum height or weight limit specified by the car seat manufacturer, which is typically around 2 years of age.
Choice C reason: Placing the retainer clip across the newborn’s abdomen is incorrect. The retainer clip should be positioned at the level of the newborn’s armpits to ensure the harness straps are properly aligned and to prevent the baby from slipping out of the harness.
Choice D reason: Positioning the newborn at a 45-degree angle in the car seat is correct. This angle helps keep the newborn’s airway open and reduces the risk of airway obstruction. It also ensures that the baby is securely positioned in the seat.
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