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.
Assist the client to a side-lying position.
Provide oral hygiene.
The Correct Answer is A
Choice A rationale
Withholding oral fluids and food is the priority because it reduces pancreatic stimulation and decreases the secretion of pancreatic enzymes, preventing further autodigestion and inflammation of the pancreas.
Choice B rationale
Auscultating the client's lungs is important to check for complications such as pleural effusion or atelectasis, but it is not the immediate priority after pain management.
Choice C rationale
Assisting the client to a side-lying position can help with comfort and may ease breathing, but it does not directly address the underlying issue of pancreatic inflammation.
Choice D rationale
Providing oral hygiene is essential for overall care but does not impact the acute management of pancreatitis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Metabolic acidosis is characterized by a low pH and decreased HCO₃ levels, not increased PaCO₂.
Choice B rationale
Metabolic alkalosis presents with an elevated pH and increased HCO₃ levels, which do not match the given values.
Choice C rationale
Respiratory alkalosis is indicated by a high pH and decreased PaCO₂, opposite of the provided values.
Choice D rationale
Respiratory acidosis is identified by a low pH, elevated PaCO₂, and normal HCO₃, aligning with the provided values.
Correct Answer is ["A","C","F","G","H"]
Explanation
Choice A rationale:
The Glasgow Coma Scale score has decreased from 14 to 12, indicating a decline in the client's level of consciousness. This finding requires immediate attention as it may signify worsening neurological status or an underlying condition such as metabolic disturbances, hypoxia, or intracranial pathology.
Choice C rationale:
The bicarbonate level is 13 mEq/L, which is significantly lower than the normal range of 21-28 mEq/L. This indicates metabolic acidosis, a condition where the blood is too acidic. It requires immediate intervention to prevent severe complications such as shock or organ failure.
Choice F rationale:
The client's blood pressure readings show hypotension with a supine blood pressure of 100/70 mm Hg and sitting blood pressure of 85/50 mm Hg. This suggests hemodynamic instability, which could be due to dehydration, sepsis, or other critical conditions requiring urgent treatment.
Choice G rationale:
The ECG findings indicate tachycardia with a prolonged PR interval, widened QRS complex, and peaked T waves. These are signs of hyperkalemia, a potentially life-threatening condition requiring immediate attention to prevent cardiac arrest.
Choice H rationale:
The sodium level is 152 mEq/L, which is higher than the normal range of 136-145 mEq/L, indicating hypernatremia. This electrolyte imbalance can lead to severe neurological symptoms and requires prompt correction to prevent complications such as seizures or coma.
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