A nurse plans care for a patient with acute pancreatitis. Which intervention would the nurse include in this patient's plan of care to reduce discomfort?

Maintain nothing by mouth (NPO) and administer intravenous fluids.

Provide small, frequent feedings with no concentrated sweets.

Administer morphine sulfate intramuscularly every 4 hours as needed.

Position the patient in a flat, supine position to decrease discomfort.

Answer and Explanation

The Correct Answer is A

Choice A reason: Maintaining nothing by mouth (NPO) and administering intravenous fluids is the best intervention to reduce discomfort in a patient with acute pancreatitis. NPO status helps to rest the pancreas by preventing the secretion of pancreatic enzymes that can exacerbate inflammation and pain. Intravenous fluids are essential to maintain hydration and electrolyte balance while the patient is not eating or drinking.

Choice B reason: Providing small, frequent feedings with no concentrated sweets is not appropriate for a patient with acute pancreatitis. The priority is to keep the patient NPO to rest the pancreas. Introducing any food can stimulate the pancreas and worsen the condition.

Choice C reason: Administering morphine sulfate intramuscularly every 4 hours as needed can help manage pain, but the preferred route for pain medication in acute pancreatitis is intravenous, as it provides quicker relief and avoids the discomfort of intramuscular injections. Pain management is important, but it should be part of a broader plan that includes NPO status and IV fluids.

Choice D reason: Positioning the patient in a flat, supine position is not recommended for reducing discomfort in acute pancreatitis. Patients often find relief in a semi-Fowler's position (head elevated) or by leaning forward, which can help reduce abdominal pain and pressure on the inflamed pancreas.

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Correct Answer is C,D,A,B

Explanation

Choice A reason: Assessing the client's respiratory status is the top priority action. This ensures that any immediate issues with breathing or oxygenation are identified and managed promptly. Respiratory status can quickly deteriorate in patients with heart failure, and addressing this first can be life-saving.

Choice B reason: Drawing blood to assess the patient's serum electrolytes is important to determine any imbalances that need immediate correction. Electrolyte levels can affect heart function and overall stability, so understanding the patient's current status helps guide further treatment.

Choice C reason: Administering the prescribed intravenous furosemide (Lasix) is critical for managing fluid overload in heart failure. Furosemide helps reduce fluid retention and alleviate symptoms such as pulmonary edema, which can improve respiratory status and overall comfort.

Choice D reason: Asking the patient about an advanced directive is important for understanding their wishes and planning care accordingly. However, it is not an immediate priority compared to stabilizing the patient's respiratory status and addressing urgent medical needs.

A. Regulation of water balance B. Regulation of acid-base balance C. Regulation of blood pressure D. Regulation of metabolic wastes

Correct Answer is A

Explanation

Choice A reason: The regulation of water balance by the kidneys involves maintaining the appropriate volume and concentration of body fluids. By taking daily weights, nurses can assess fluid retention or loss, while monitoring intake and output (I&O) helps track fluid balance. Specific gravity measures the concentration of urine, which provides information about the kidneys' ability to concentrate or dilute urine. These interventions directly relate to the kidneys' role in regulating water balance.

Choice B reason: Regulation of acid-base balance by the kidneys involves maintaining the proper pH levels in the blood through excretion or retention of hydrogen ions and bicarbonate. While important, this function is not the primary focus of interventions like daily weights, I&O, and specific gravity monitoring, which are more related to water balance.

Choice C reason: The regulation of blood pressure by the kidneys is achieved through the renin-angiotensin-aldosterone system, which controls blood volume and systemic vascular resistance. Although fluid balance can indirectly affect blood pressure, the specific interventions mentioned are more directly related to water balance than blood pressure regulation.

Choice D reason: Regulation of metabolic wastes involves the kidneys filtering and excreting waste products from the blood. This function is vital for overall health, but interventions like daily weights, I&O, and specific gravity monitoring are more focused on assessing fluid balance rather than directly measuring waste elimination.

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A nurse plans care for a patient with acute pancreatitis. Which intervention would the nurse include in this patient's plan of care to reduce discomfort?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse admits a patient who is experiencing an exacerbation of heart failure. Drag and drop in order of priority actions.

Correct Answer is C,D,A,B

Explanation

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Correct Answer is A

Explanation

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