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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While it’s important to prepare for a barium swallow test, maintaining a clear liquid diet 24 hours before the test is not typically required.
Choice B rationale
Drinking plenty of fluids after the test is indeed a correct instruction. The barium used in the test can cause constipation or impacted stool if it does not pass out of the body. Drinking ample fluids helps flush the contrast from the gastrointestinal system.
Choice C rationale
While it’s true that the stool may be discolored after a barium swallow test, it’s more likely to be lighter or white, not black.
Choice D rationale
The barium swallow test does not involve the injection of any dye that would cause a warm feeling. This sensation is more commonly associated with the injection of contrast dye in other types of imaging tests, not a barium swallow.
Correct Answer is A
Explanation
Choice A rationale
The UREA breath test is used to detect Helicobacter pylori (H. pylori), a type of bacteria that may infect the stomach and is a main cause of ulcers in both the stomach and duodenum (the first part of the small intestine).
H. pylori produces an enzyme called urease, which breaks urea down into ammonia and carbon dioxide. During the test, a tablet containing urea is swallowed and the amount of exhaled carbon dioxide is measured. This indicates the presence of H. pylori in the stomach. Therefore, the UREA breath test measures urea levels to determine if H. pylori is present.
Choice B rationale
While it is true that the presence of Helicobacter pylori antibodies in the blood can indicate an
H. pylori infection, this is typically detected using a blood test, not a UREA breath test. The UREA breath test specifically measures the amount of carbon dioxide in your breath after you drink a special solution containing urea.
H. pylori bacteria break down urea into carbon dioxide, and excess carbon dioxide in your breath is a sign of an H. pylori infection. Therefore, while Helicobacter pylori antibodies can indicate an H. pylori infection, they are not the lab value that the UREA breath test measures to determine if H. pylori is present.
Choice C rationale
Gastrin levels are not measured in a UREA breath test. Gastrin is a hormone that stimulates the production of gastric acid, which helps the stomach digest food. While gastrin levels can be elevated in individuals with certain conditions, such as gastrinomas or Zollinger-Ellison syndrome, they are not directly related to H. pylori infections or measured in a UREA breath test.
Choice D rationale
Pepsinogen levels are not measured in a UREA breath test. Pepsinogen is a precursor enzyme (zymogen) produced by the gastric chief cells, and it is converted to the enzyme pepsin in the presence of stomach acid. While pepsinogen levels can be used to assess certain conditions, such as atrophic gastritis, they are not directly related to H. pylori infections or measured in a UREA breath test.
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