The nurse identifies the collaborative problem of potential electrolyte imbalance in a client with acute pancreatitis. Which assessment finding should the nurse associate with an electrolyte imbalance related to acute pancreatitis?
Hyperglycemia.
Hypotension.
Paralytic ileus and abdominal distention.
Muscle twitching and digit numbness.
The Correct Answer is D
A. Hyperglycemia. While elevated blood glucose can occur in acute pancreatitis due to pancreatic inflammation impairing insulin secretion, it is not an electrolyte imbalance. The question specifically asks about electrolyte-related manifestations.
B. Hypotension. Hypotension in acute pancreatitis is often due to fluid shifts (third-spacing) and systemic inflammation, rather than a direct electrolyte imbalance. Though dehydration and electrolyte losses can contribute to hypotension, this is not the most specific sign of an electrolyte disturbance.
C. Paralytic ileus and abdominal distention. Hypokalemia can lead to paralytic ileus, but ileus and distention are also caused by peritoneal irritation, inflammation, and impaired motility due to pancreatitis itself. While potassium imbalance could contribute, this is not the most direct electrolyte-related symptom.
D. Muscle twitching and digit numbness. Hypocalcemia is a common electrolyte imbalance in acute pancreatitis, caused by fatty acid breakdown binding calcium, leading to saponification. This results in neuromuscular excitability, causing muscle twitching, paresthesia (numbness/tingling), and positive Chvostek’s or Trousseau’s signs. These symptoms are clear indicators of an electrolyte disturbance related to pancreatitis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Heparin is infused in less than four hours. The heparinized solution used in an intra-arterial (IA) pressure infuser is not intended for systemic anticoagulation but rather to maintain catheter patency. The infusion rate is typically slow and continuous, and completing the infusion in less than four hours is not an indicator of effectiveness.
B. Systolic blood pressure greater than 120 mm Hg. Heparin in an IA pressure infuser does not directly affect blood pressure. Its purpose is to prevent clot formation within the catheter, ensuring uninterrupted arterial pressure monitoring. BP readings are monitored separately and are not an indicator of heparin’s therapeutic effect.
C. No knee pain upon forced dorsiflexion. This assessment is used to evaluate deep vein thrombosis (DVT) (Homan's sign), which is not related to arterial catheter function. The low-dose heparin in the pressure infuser does not provide systemic anticoagulation, making this finding irrelevant.
D. Intra-arterial cannula remains patent. The primary purpose of heparinized flush solutions in IA lines is to prevent clot formation within the catheter and maintain patency for continuous blood pressure monitoring or arterial blood sampling. A patent arterial line confirms that the heparin infusion is achieving its intended effect.
Correct Answer is C
Explanation
A. Place a cooling blanket on the client. A temperature of 100°F (37.8°C) is only mildly elevated and does not require active cooling. The priority concern is hemodynamic instability due to hypovolemia, not fever management. Cooling blankets are typically used for high fevers (≥ 102°F or 38.9°C).
B. Administer an antipyretic agent. While fever may indicate postoperative infection or inflammatory response, the client’s most critical issue is hypotension and low urine output, suggesting hypovolemia or early shock. Treating the underlying cause (fluid loss) is more urgent than giving an antipyretic.
C. Give a 500 mL IV fluid bolus challenge. The client has tachycardia (132 bpm), hypotension (88/65 mm Hg), and oliguria (10 mL/hour), all of which suggest hypovolemic shock, a common postoperative complication. A fluid bolus (typically 500–1000 mL of isotonic crystalloid such as normal saline or lactated Ringer’s) is the first-line treatment to restore intravascular volume, improve blood pressure, and increase urine output.
D. Titrate IV vasopressor for systolic less than 80. Vasopressors (e.g., norepinephrine) are not the first-line treatment for hypovolemic shock. Fluids should be administered first to correct volume loss before considering vasopressors. If hypotension persists despite adequate fluid resuscitation, vasopressors may be initiated.
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