A client diagnosed with pancreatitis is reporting severe epigastric pain and intense nausea.
After the nurse administers a narcotic analgesic and an antiemetic, the client insists on sitting up and leaning forward. Which action should the nurse implement?
Reinforce bed rest until analgesic is effective.
Place bed in reverse Trendelenburg position.
Raise head of bed until at a 90-degree angle.
Position bedside table for client to lean across.
The Correct Answer is D
A. Reinforcing bed rest until the analgesic is effective may not address the client's need to sit up and lean forward. It's important to respond to the client's discomfort and find a position that
provides relief.
B. Placing the bed in reverse Trendelenburg position (head elevated, feet lowered) may not be the most effective position for a client experiencing severe epigastric pain and nausea. This
position could potentially worsen symptoms or discomfort.
C. Raising the head of the bed to a 90-degree angle may not provide optimal relief for the client.
While it's essential to elevate the head of the bed for comfort and to prevent aspiration, it may not address the client's specific need to lean forward.
D. Positioning a bedside table for the client to lean across allows the client to assume a position that often provides relief for epigastric pain associated with pancreatitis. Leaning forward can
help reduce pressure on the pancreas and alleviate discomfort. This position also facilitates drainage of gastric contents and may help alleviate nausea.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Having the client breathe into a paper bag is a technique sometimes used for anxiety-induced hyperventilation but is not appropriate for a client with chronic obstructive lung disease
experiencing shortness of breath. It can lead to a buildup of carbon dioxide, worsening the client's condition.
B. Asking the client to take short, rapid breaths may exacerbate hyperventilation and increase the client's anxiety. This breathing pattern can lead to further respiratory distress in a client with
chronic obstructive lung disease.
C. Instructing the client in pursed lip breathing is the most appropriate action. Pursed lip breathing helps to prolong exhalation, reduce air trapping, and improve gas exchange in clients with chronic obstructive lung disease. It can help alleviate shortness of breath and promote
relaxation.
D. Increasing oxygen to three L/minute may not be necessary and could potentially lead to oxygen toxicity. The priority is to help the client manage their shortness of breath effectively through breathing techniques.
Correct Answer is B
Explanation
A. Connecting the nasogastric tube to high continuous suction without further assessment or intervention is not appropriate and could exacerbate the situation.
B. Clamping the nasogastric tube and contacting the healthcare provider is the correct action. "Coffee ground" drainage can indicate the presence of blood in the stomach, which may require further evaluation and intervention by the healthcare provider.
C. Connecting the nasogastric tube to suction as prescribed without addressing the presence of "coffee ground" drainage is not appropriate. It's important to assess the significance of this finding before proceeding with suctioning.
D. Immediately removing and then reinserting the nasogastric tube may not be necessary and could increase the risk of trauma or complications. It's important to assess the situation further and involve the healthcare provider in decision-making.
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