When planning care for a client with acute pancreatitis, which nursing intervention has the highest priority?

Administer antiemetics as needed.

Withhold food and fluid intake.

Evaluate intake and output ratio.

Initiate IV fluid replacement.

Answer and Explanation

The Correct Answer is D

A. Administering antiemetics is important for symptom management but does not address the primary issue of fluid balance and pancreatic inflammation.

B. Withholding food and fluid intake is a necessary intervention for managing acute pancreatitis, but it is secondary to ensuring adequate fluid resuscitation.

C. Evaluating intake and output is important for monitoring fluid balance but is less critical than initiating fluid replacement.

D. Initiating IV fluid replacement is the highest priority as it addresses the risk of dehydration and maintains hemodynamic stability, which is crucial in acute pancreatitis management.

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Correct Answer is C

Explanation

A. Assessing papillary reactions to light is important in a neurological assessment but is not the priority in this situation.

B. Measuring and recording abdominal girth is not relevant to the client's current symptoms.

C. Auscultating over the main stem bronchus is the priority action as the client's symptoms suggest potential airway compromise, possibly from inhalation injury or swelling. Early identification and management of airway issues are critical in burn patients.

D. Determining the time of last oral intake is part of a comprehensive assessment but is not the immediate priority when airway compromise is suspected.

A. "Hyperglycemia often results in weight loss." B. "Hyperglycemia causes cool and clammy skin." C. "Hyperglycemia causes an increased sensation of being hungry." D. "Hyperglycemia causes a headache and flushed, dry skin." E. "Hyperglycemia often presents as increased thirst and urination."

Correct Answer is ["D","E"]

Explanation

A. "Hyperglycemia often results in weight loss.": Weight loss is more commonly associated with prolonged hyperglycemia, particularly in uncontrolled diabetes where the body starts breaking down fat and muscle for energy.

B. "Hyperglycemia causes cool and clammy skin.": Cool and clammy skin is more indicative of hypoglycemia (low blood sugar) rather than hyperglycemia.

C. "Hyperglycemia causes an increased sensation of being hungry.": Increased hunger is often associated with hypoglycemia or uncontrolled diabetes, where insulin is not effectively managing blood glucose levels.

D. "Hyperglycemia causes a headache and flushed, dry skin.": In cases of significant hyperglycemia, symptoms can include headache and flushed, dry skin due to dehydration. These symptoms arise from the body’s attempt to balance blood sugar levels and manage dehydration.

E. "Hyperglycemia often presents as increased thirst and urination.": Hyperglycemia typically leads to increased thirst (polydipsia) and increased urination (polyuria). This occurs because the body tries to get rid of excess glucose through the urine, leading to dehydration and increased thirst.

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When planning care for a client with acute pancreatitis, which nursing intervention has the highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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