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 B

Explanation

A. Family history of schizophrenia is relevant but not immediately critical.

B. A history of suicide attempts indicates a high risk of self-harm and requires immediate attention in the plan of care.

C. Social anxiety symptoms are important but not as critical as addressing suicide risk.

D. Disorientation needs assessment but is not as urgent as managing suicide risk.

A. client is 3 cm dilated, 40% effaced, and the fetal head is at -1 station B. contractions are occurring every 4 minutes and lasting 70 seconds C. fasting blood glucose (FSBG) is 86 (4.8 mmol/L) D. client dilates quickly to 10 cm and feels a strong urge to push E. fetal heart rate is reassuring with a baseline of 145 and moderate variability F. Apgar of 7 at 1 minute, then 9 at 5 minutes G. After three cycles of open-glottis pushing, the baby's head is crowning H. infant weighs 9 lbs. 9 oz I. membranes rupture at 38 weeks gestation

Correct Answer is ["A","B","C","D","E","F"]

Explanation

This blood glucose level is within the normal range, indicating that the client’s blood sugar is well-controlled at this point.

The client is 3 cm dilated, 40% effaced, with contractions every 4 minutes lasting 70 seconds and strong in quality. These are signs of active labor progressing appropriately.

The fetal heart rate is reassuring with a baseline of 145 beats per minute and moderate variability. This indicates good fetal well-being and adequate oxygenation.

The client quickly dilates to 10 cm and experiences a strong urge to push, suggesting efficient progress through labor.

The baby is born with an intact perineum, weighs 9 lbs. 9 oz (4.34 kg), and has excellent Apgar scores of 7 at 1 minute and 9 at 5 minutes. These scores indicate that the infant is in good condition and adapting well to extrauterine life.

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

Nursing Test Bank

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Explanation

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