A nurse is planning care for a client who has acute pancreatitis. Which of the following interventions should the nurse include in the client’s plan? (Select all that apply.)

Initiate insulin drip.

Monitor blood glucose levels.

Continue regular diet as tolerated.

Maintain NPO status until pain-free.

Manage acute pain.

Answer and Explanation

Correct Answer : B,E

Choice A Reason:

Initiating an insulin drip is not a standard intervention for all clients with acute pancreatitis. This intervention is typically reserved for clients who develop hyperglycemia or diabetes as a complication of pancreatitis. Acute pancreatitis can affect the pancreas’ ability to produce insulin, but not all clients will require an insulin drip.

Choice B Reason:

Monitoring blood glucose levels is crucial for clients with acute pancreatitis because the pancreas plays a key role in regulating blood sugar. Inflammation or damage to the pancreas can lead to fluctuations in blood glucose levels, making regular monitoring essential to manage potential hyperglycemia or hypoglycemia.

Choice C Reason:

Continuing a regular diet as tolerated is not appropriate for clients with acute pancreatitis. These clients are typically kept NPO (nothing by mouth) to rest the pancreas and reduce the secretion of pancreatic enzymes, which can exacerbate inflammation and pain.

Choice D Reason:

Maintaining NPO status until the client is pain-free is a standard intervention for acute pancreatitis. This approach helps to rest the pancreas and prevent the release of digestive enzymes that can further inflame the pancreas. Once the client is pain-free and inflammation has subsided, a gradual reintroduction of oral intake can be considered.

Choice E Reason:

Managing acute pain is a critical aspect of care for clients with acute pancreatitis. Pain management can include medications such as opioids, as well as non-pharmacological interventions like positioning and relaxation techniques. Effective pain management improves the client’s comfort and can help reduce stress on the pancreas.

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Correct Answer is C

Explanation

Choice A Reason:

Remaining 1 meter (3 feet) away from the client when providing care is not sufficient to prevent the spread of tuberculosis (TB). TB is an airborne disease, and the bacteria can remain suspended in the air for several hours. Therefore, maintaining a distance alone does not provide adequate protection against inhaling the bacteria.

Choice B Reason:

Applying a surgical mask before entering the client’s room is not the most effective measure. Surgical masks are designed to protect against large droplets and splashes, but they do not provide adequate protection against airborne particles like TB bacteria. Instead, healthcare workers should use N95 respirators, which are specifically designed to filter out airborne particles.

Choice C Reason:

Ensuring the door to the client’s room is closed at all times is a critical measure in preventing the spread of TB. This action helps to contain the airborne bacteria within the room, reducing the risk of transmission to others in the healthcare facility. This is part of airborne precautions, which are essential for managing patients with active TB.

Choice D Reason:

Placing a “no visitors” sign on the client’s door can help limit the number of people exposed to the TB bacteria, but it is not the most critical action. While it is important to restrict visitors, ensuring the door is closed and using appropriate personal protective equipment (PPE) are more effective measures in controlling the spread of TB.

A. Diazepam IV B. Lorazepam PO C. Diltiazem IV D. Clonazepam PO

Correct Answer is A

Explanation

Choice A Reason

Diazepam IV is the correct choice for managing repeated tonic-clonic seizures, especially in the context of status epilepticus. Diazepam is a benzodiazepine that acts quickly to stop seizures by enhancing the effect of the neurotransmitter GABA. It is commonly used in emergency settings due to its rapid onset of action when administered intravenously.

Choice B Reason

Lorazepam PO is not the best choice in this scenario. While lorazepam is also a benzodiazepine effective in stopping seizures, the oral route is not suitable for immediate control of seizures. Intravenous administration is preferred for rapid action.

Choice C Reason

Diltiazem IV is incorrect. Diltiazem is a calcium channel blocker used primarily for managing hypertension and certain types of arrhythmias. It is not indicated for the treatment of seizures.

Choice D Reason

Clonazepam PO is not appropriate for immediate seizure control. Although clonazepam is a benzodiazepine used for seizure management, the oral route is not effective for rapid seizure termination. Intravenous administration of a benzodiazepine like diazepam or lorazepam is preferred.

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A nurse is planning care for a client who has acute pancreatitis. Which of the following interventions should the nurse include in the client’s plan? (Select all that apply.)

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