When providing care for a client hospitalized with acute pancreatitis who has acute abdominal pain, which nursing interventions would be most appropriate for this client? Select all that apply.

Place the client in a side-lying position.

Administer hydromorphone for pain as prescribed.

Obtain daily weights.

Maintain a high-calorie, high-protein diet.

Monitor the client's respiratory status.

Answer and Explanation

Correct Answer : A,B,E

Choice A reason: Placing the client in a side-lying position is beneficial for comfort and can help alleviate pain in clients with acute pancreatitis. This position can reduce pressure on the pancreas and improve circulation, helping to manage pain and discomfort effectively.

Choice B reason: Administering hydromorphone for pain as prescribed is essential in managing acute abdominal pain associated with acute pancreatitis. Pain control is a priority in the care of these clients because unmanaged pain can lead to increased stress and further complications. Hydromorphone, a potent opioid analgesic, helps to effectively manage severe pain.

Choice C reason: Obtaining daily weights is important for monitoring a client's nutritional status and fluid balance, but it is not directly related to the immediate management of acute abdominal pain in acute pancreatitis. While it is a relevant intervention, it is not as critical as the other measures listed.

Choice D reason: Maintaining a high-calorie, high-protein diet is not appropriate for a client with acute pancreatitis. In fact, clients with acute pancreatitis are often placed on a nil-per-os (NPO) status initially to rest the pancreas and reduce enzyme secretion. Once the inflammation subsides, a low-fat, bland diet may be introduced gradually.

Choice E reason: Monitoring the client's respiratory status is crucial because clients with acute pancreatitis are at risk for respiratory complications, such as pleural effusion, acute respiratory distress syndrome (ARDS), or atelectasis. Close monitoring ensures early detection and intervention for any respiratory issues that may arise.

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Correct Answer is C

Explanation

Choice A reason: Aspirin does have analgesic properties, which help relieve pain. However, this is not the primary reason for its administration in the context of angina-like chest pain. The analgesic effect of aspirin without sedation is more relevant in the management of general pain or headaches.

Choice B reason: Vasoconstriction and improved blood flow are not effects of aspirin. In fact, aspirin's mechanism of action involves preventing platelet aggregation, which can indirectly improve blood flow by reducing the risk of clot formation. Vasoconstriction is not an effect associated with aspirin.

Choice C reason: The primary rationale for administering aspirin to a client with angina-like chest pain is its antiplatelet effect. Aspirin inhibits platelet aggregation, reducing the risk of clot formation. This is crucial in preventing further blockage of coronary arteries, which can exacerbate angina or lead to myocardial infarction.

Choice D reason: Cardiotonic properties and improved contraction are not associated with aspirin. Cardiotonic drugs enhance the strength of the heart's contractions, which is not an action of aspirin. Aspirin's role in this context is to prevent platelet aggregation and reduce the risk of clot-related complications.

A. I must stop halfway up the stairs to catch my breath. B. I am awakened by the need to urinate at night. C. I have been drinking more water than usual. D. I have experienced blurred vision on several occasions.

Correct Answer is A

Explanation

Choice A reason: The statement "I must stop halfway up the stairs to catch my breath" is a significant indicator of left-sided heart failure. Left-sided heart failure leads to pulmonary congestion, resulting in symptoms such as shortness of breath, especially during physical activities. This occurs because the heart is unable to effectively pump blood to the body, causing fluid buildup in the lungs and leading to exertional dyspnea.

Choice B reason: The statement "I am awakened by the need to urinate at night" refers to nocturia, which can be associated with heart failure but is not as specific to left-sided heart failure as exertional dyspnea. Nocturia can occur due to fluid redistribution when lying down, but it is not a definitive sign of left-sided heart failure alone.

Choice C reason: The statement "I have been drinking more water than usual" is not directly related to left-sided heart failure. Increased water intake could be indicative of other conditions such as diabetes or dehydration, but it is not a specific symptom of left-sided heart failure.

Choice D reason: The statement "I have experienced blurred vision on several occasions" is not typically associated with left-sided heart failure. Blurred vision can result from various causes, including visual disturbances, blood pressure changes, or other medical conditions, but it is not a hallmark symptom of left-sided heart failure.

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When providing care for a client hospitalized with acute pancreatitis who has acute abdominal pain, which nursing interventions would be most appropriate for this client? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse correlates which rationale with the administration of aspirin to the client experiencing angina-like chest pain?

Correct Answer is C

Explanation

A nurse assesses a patient in an outpatient clinic. Which statement alerts the nurse to the possibility of left-sided heart failure?

Correct Answer is A

Explanation

A nurse in an emergency department is reviewing the medical record of a client who has an extensive burn injury. Which of the following laboratory results should the nurse expect?

The nurse notes that a client with acute pancreatitis occasionally experiences muscle twitching and jerking. How should the nurse interpret the relevance of these symptoms?

The client is receiving IV doses of Vancomycin every 12 hours. Which would be the nurse's priority to monitor for complications during the period that the patient is receiving this drug?

To determine treatment effectiveness in a patient with pancreatitis, the nurse should monitor which of these tests?

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The emergency department nurse can expect to see which assessment cues in the patient with acute pancreatitis? Select all that apply.

A 35-year-old patient arrives at the Emergency Department in acute respiratory failure. What assessment information does the nurse prioritize as needing immediate action?

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