A nurse is contributing to the care plan for a patient who has acute pancreatitis.
Which of the following interventions should the nurse include?
Monitor peripheral pulses every 8 hours
Measure urine output every 4 hours
Maintain NPO status
Ambulate the patient three times daily
The Correct Answer is C
Choice A rationale
Monitoring peripheral pulses every 8 hours is not typically a priority in the care plan for a patient with acute pancreatitis. While cardiovascular monitoring is important in all patients, it is not specifically related to the management of acute pancreatitis.
Choice B rationale
Measuring urine output every 4 hours can be important in assessing fluid balance and kidney function, but it is not the primary intervention in the care plan for a patient with acute pancreatitis.
Choice C rationale
Maintaining NPO (nothing by mouth) status is a key intervention in the management of acute pancreatitis. This helps to rest the pancreas and reduce the production of digestive enzymes.
Choice D rationale
Ambulating the patient three times daily is generally a good practice for postoperative recovery, but it is not specific to the care of a patient with acute pancreatitis. In the acute phase of pancreatitis, rest is often recommended.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
No stool noted in the collection bag is not an immediate concern as it can take several days for the bowel to start functioning after surgery.
Choice B rationale
A bluish-purplish colored stoma could indicate inadequate blood supply to the stoma, which is a medical emergency and should be reported to the provider immediately.
Choice C rationale
An edematous stoma is a common finding in the immediate postoperative period.
Choice D rationale
Slight bleeding of the stoma site can be a normal finding after colostomy placement.
Correct Answer is B
Explanation
Choice A rationale
Ecchymosis of the extremities is not a typical finding in a patient with an obstruction and inflammation of the common bile duct due to cholelithiasis.
Choice B rationale
Fatty stools, or steatorrhea, is a common symptom in patients with cholelithiasis. This is because the obstruction in the common bile duct can prevent the flow of bile, which is necessary for the digestion and absorption of fats.
Choice C rationale
Straw-colored urine is not typically associated with cholelithiasis. Dark urine can be a symptom of this condition, as the obstruction can cause bilirubin to leak into the blood and urine.
Choice D rationale
Tenderness in the left upper abdomen is not a typical symptom of cholelithiasis. Pain associated with this condition is usually located in the right upper quadrant or the middle upper part of the abdomen.
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