The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? (Select all that apply)
Maintain NPO (nothing by mouth) status.
Encourage coughing and deep breathing.
Give small, frequent high-calorie feedings.
Maintain the client in a supine and flat position.
Give hydromorphone intravenously as prescribed for pain.
Maintain intravenous fluids at 10 mL/hr to keep the vein open.
Correct Answer : A,B,E
Choice A reason: NPO status rests the pancreas, reducing enzyme secretion in acute pancreatitis. This aligns with treatment protocols, making it a correct intervention the nurse would expect to be prescribed for the client to manage pancreatic inflammation effectively.
Choice B reason: Coughing and deep breathing prevent respiratory complications like atelectasis in pancreatitis patients, who are often immobile. This aligns with standard care, making it a correct intervention the nurse would anticipate in the client’s treatment plan.
Choice C reason: Small, frequent high-calorie feedings are contraindicated in acute pancreatitis, as they stimulate the pancreas. NPO is correct, making this incorrect, as it’s inappropriate for the nurse’s expected interventions in managing acute pancreatitis.
Choice D reason: Supine and flat positioning may increase discomfort and aspiration risk in pancreatitis. Semi-Fowler’s is preferred, making this incorrect, as it’s not an expected intervention compared to the nurse’s focus on optimal positioning for the client.
Choice E reason: Hydromorphone IV provides effective pain relief in acute pancreatitis, reducing patient discomfort. This aligns with pain management protocols, making it a correct intervention the nurse would expect to be prescribed for the client’s care.
Choice F reason: IV fluids at 10 mL/hr are insufficient for pancreatitis, which requires aggressive hydration. Higher rates are standard, making this incorrect, as it’s inadequate compared to the nurse’s expected fluid management in acute pancreatitis treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["D","E","F"]
Explanation
Choice A reason: Diarrhea is less common in acute pancreatitis, which typically causes nausea and vomiting. Flank discoloration is a specific sign, making this incorrect, as it’s not a primary finding the nurse would expect in the assessment of acute pancreatitis.
Choice B reason: Black tarry stools indicate upper GI bleeding, not pancreatitis, which causes pain and guarding. Left quadrant pain is typical, making this incorrect, as it’s unrelated to the nurse’s expected findings in a client with suspected acute pancreatitis.
Choice C reason: Hyperactive bowel sounds suggest obstruction, not pancreatitis, which often causes hypoactive sounds due to inflammation. Abdominal tenderness is correct, making this incorrect, as it doesn’t align with the nurse’s anticipated findings in acute pancreatitis assessment.
Choice D reason: Gray, including its reasoning, and a gray-blue flank (Cullen’s or Grey Turner’s sign) indicates severe pancreatitis with hemorrhage. This aligns with severe pancreatitis assessment, making it a correct finding the nurse would expect in suspected acute pancreatitis.
Choice E reason: Abdominal guarding and tenderness result from pancreatic inflammation, common in acute pancreatitis. This aligns with abdominal assessment findings, making it a correct manifestation the nurse would identify in a client with suspected acute pancreatitis.
Choice F reason: Left upper quadrant pain radiating to the back is classic in acute pancreatitis due to pancreatic inflammation. This aligns with clinical assessment, making it a correct finding the nurse would expect in a client with suspected acute pancreatitis.
Correct Answer is D
Explanation
Choice A reason: Leafy greens contain iron, but water doesn’t enhance absorption; vitamin C does. Calf’s liver with orange juice maximizes absorption, making this incorrect, as it lacks the vitamin C component the nurse should teach to improve iron uptake in anemia.
Choice B reason: Apples and carrots have minimal iron and no vitamin C to enhance absorption. Calf’s liver with orange juice is optimal, making this incorrect, as it doesn’t provide iron or absorption enhancers compared to the nurse’s teaching for iron deficiency anemia.
Choice C reason: Steak is iron-rich, but mushrooms don’t significantly enhance absorption like vitamin C. Orange juice with liver is better, making this incorrect, as it’s less effective than the nurse’s recommendation to pair iron with a vitamin C source for anemia.
Choice D reason: Calf’s liver is high in iron, and orange juice’s vitamin C enhances non-heme iron absorption. This aligns with nutritional education for iron deficiency anemia, making it the correct choice for the nurse to teach the client to improve iron absorption effectively.
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