In planning the care for a patient with acute pancreatitis, the nurse should make which of these goals the highest?

Effective pain management.

Decrease patient anxiety.

Adequate hydration achieved.

Decrease potassium intake.

Answer and Explanation

The Correct Answer is A

Choice A reason: Effective pain management is the highest priority in the care of a patient with acute pancreatitis. Severe abdominal pain is a hallmark of acute pancreatitis and can significantly impact the patient's comfort and ability to participate in other aspects of their care. Managing pain effectively helps improve the patient's overall well-being and allows for better participation in treatments and recovery.

Choice B reason: Decreasing patient anxiety is important, but it is not the primary goal in the acute management of pancreatitis. Addressing anxiety can help improve the patient's experience and adherence to treatment, but managing pain and hydration are more critical in the immediate care.

Choice C reason: Adequate hydration is crucial in the management of acute pancreatitis, as dehydration can worsen the condition and lead to complications. However, pain management takes precedence because uncontrolled pain can lead to further stress and complications, hindering the effectiveness of hydration and other treatments.

Choice D reason: Decreasing potassium intake is not a primary goal in the management of acute pancreatitis. While electrolyte balance is important, there is no direct indication that potassium levels need to be specifically managed unless there is a documented imbalance. The focus should be on pain management and hydration.

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Correct Answer is D

Explanation

Choice A reason: A heart rate of 56/min and a blood pressure of 110/70, while slightly lower than normal, may not require immediate intervention unless accompanied by other symptoms. Bradycardia (a slow heart rate) and this blood pressure reading can be within acceptable limits for some individuals, especially if they are asymptomatic.

Choice B reason: Mitral valve regurgitation with a thready peripheral pulse indicates a decrease in cardiac output, which can be concerning. However, it may not require immediate intervention unless the client shows signs of severe decompensation or other critical symptoms. Continuous monitoring and evaluation are essential, but immediate action might not be necessary.

Choice C reason: Chest pain with inspiration in a client with pericarditis can be a symptom of the condition itself, which involves inflammation of the pericardium. While pain management and monitoring are important, this symptom alone may not necessitate immediate intervention unless it is severe or accompanied by other alarming signs.

Choice D reason: The development of slurred speech in a client with a history of atrial fibrillation is a critical symptom that warrants immediate intervention. Slurred speech can be a sign of a stroke or transient ischemic attack (TIA), both of which require urgent medical attention. Immediate action is needed to evaluate and manage the client's condition to prevent further complications.

A. Patient with urine output of 40 mL/hr for the last hour. B. Patient with a blood pressure change of 128/74 to 110/88 mmHg. C. Patient with oxygen saturation maintained at 94%. D. Patient with a pulse change of 100 to 88 beats/min.

Correct Answer is B

Explanation

Choice A reason: A urine output of 40 mL/hr is within the acceptable range, as normal urine output is typically around 30-50 mL/hr. While it should be monitored, it does not indicate an immediate life-threatening issue requiring urgent assessment.

Choice B reason: A blood pressure change from 128/74 to 110/88 mmHg may indicate potential hemodynamic instability. Although the systolic blood pressure has decreased, the diastolic pressure has increased, which can be concerning. This patient may be at risk for developing more significant blood pressure changes or other complications, making this situation the highest priority for assessment.

Choice C reason: An oxygen saturation level of 94% is generally considered acceptable. While it is on the lower end of the normal range, it does not indicate an immediate life-threatening condition. Continuous monitoring is important, but it is not the most urgent situation compared to the blood pressure change.

Choice D reason: A pulse change from 100 to 88 beats/min represents a decrease in heart rate but remains within the normal range for adult heart rate (60-100 beats/min). While this change should be noted and monitored, it is not as urgent as the blood pressure change that may indicate hemodynamic instability.

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In planning the care for a patient with acute pancreatitis, the nurse should make which of these goals the highest?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

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Correct Answer is B

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