A nurse is contributing to the plan of care for a client who has acute pancreatitis. Which of the following interventions should the nurse include?
Monitor peripheral pulses every 8 hr.
Ambulate the client three times daily.
Maintain NPO status.
Measure urine output every 4 hr.
The Correct Answer is C
Choice A rationale
Monitoring peripheral pulses every 8 hours is not a specific intervention for a client who has acute pancreatitis. While it is important to monitor peripheral pulses as part of overall patient assessment, it does not directly address the needs of a patient with acute pancreatitis.
Choice B rationale
Ambulating the client three times daily is not a specific intervention for a client who has acute pancreatitis. While physical activity is generally beneficial for overall health, it does not directly address the needs of a patient with acute pancreatitis, especially during an acute attack.
Choice C rationale
Maintaining NPO (nothing by mouth) status is a common intervention for a client who has acute pancreatitis. This allows the pancreas to rest and recover, reducing inflammation and pain.
Choice D rationale
Measuring urine output every 4 hours is not a specific intervention for a client who has acute pancreatitis. While it is important to monitor urine output as part of overall patient assessment, it does not directly address the needs of a patient with acute pancreatitis.
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Correct Answer is C
Explanation
Choice A rationale
High hemoglobin is not typically a symptom of a perforated peptic ulcer. Hemoglobin is a protein in red blood cells that carries oxygen. While changes in hemoglobin levels can indicate various health conditions, they are not directly associated with a perforated peptic ulcer.
Choice B rationale
Yellowing of the skin, or jaundice, is a symptom typically associated with liver disease, not a perforated peptic ulcer. Jaundice occurs when there’s too much bilirubin, a yellow-orange substance, in your blood.
Choice C rationale
Acute, sharp, and severe abdominal pain is a common symptom of a perforated peptic ulcer. A perforated peptic ulcer is a medical emergency that occurs when an ulcer goes through all the layers of the stomach or duodenum wall, creating a hole. This allows stomach or intestinal contents to leak into the abdominal cavity, causing severe abdominal pain.
Choice D rationale
High hematocrit is not typically a symptom of a perforated peptic ulcer. Hematocrit is the proportion of your total blood volume that is composed of red blood cells. While changes in hematocrit levels can indicate various health conditions, they are not directly associated with a perforated peptic ulcer. Dumping syndromeDumping syndrome Explore
Correct Answer is A
Explanation
Choice A rationale
Administering appropriate antibiotic therapy is a common nursing intervention to manage H. pylori infection. The recommended treatment for H. pylori typically involves using a triple-
drug therapy regimen, including a proton pump inhibitor or PPI like omeprazole, and two antibiotics, which include clarithromycin plus either metronidazole or amoxicillin. This treatment helps eradicate the bacterial infection through different mechanisms of action.
Choice B rationale
While maintaining a high-fiber diet is generally beneficial for overall health, it is not specifically related to the management of H. pylori infection. The primary treatment for H. pylori is antibiotic therapy, not dietary changes.
Choice C rationale
Over-the-counter antacids can help to neutralize stomach acid and provide temporary relief from symptoms, but they do not treat the underlying H. pylori infection. Therefore, while they may be used as part of symptom management, they are not a primary treatment strategy.
Choice D rationale
Assisting the patient with proper hand hygiene is always important in healthcare settings to prevent the spread of infections. However, it is not specifically related to the management of H. pylori infection. The bacteria are typically contracted during childhood, and the exact modes of transmission are not fully understood.
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