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.

Answer and Explanation

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.

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Correct Answer is ["A","B","D","E","G"]

Explanation

A. Prepare to prevent respiratory or cardiac arrest: The client's decreased level of consciousness and respiratory rate of 10 breaths/minute indicate a potential risk for respiratory or cardiac arrest. Immediate measures to maintain airway patency and support ventilation may be necessary.
B. Stop infusion of magnesium: The client's decreased level of consciousness and absent deep tendon reflexes (DTR) bilaterally are signs of magnesium toxicity. Stopping the infusion of magnesium sulfate is essential to prevent further complications.
C. Increasing IV fluids is not a priority in management of magnesium toxicity.
D. Obtain serum magnesium level: With signs of magnesium toxicity, obtaining a serum magnesium level is necessary to confirm the diagnosis and guide further management.
E. Administer oxygen: The client's oxygen saturation of 93% on room air indicates hypoxemia.
Administering oxygen via nasal cannula to maintain oxygen saturation greater than 96% helps prevent further respiratory compromise.
F. Obtaining blood pressure is not a priority.
G. Administer calcium gluconate: Calcium gluconate is the antidote for magnesium toxicity.
Since the client is showing signs of magnesium toxicity (decreased level of consciousness and absent DTRs), administering calcium gluconate is necessary to counteract the effects of magnesium
H. Caesarian delivery is not part of management for magnesium toicity.

A. Advise the client to maintain a voiding diary for one week. B. Obtain a urine specimen for culture and sensitivity. C. Palpate the client's suprapubic area for distention. D. Instruct in effective techniques to cleanse the glans penis.

Correct Answer is C

Explanation

A:While a voiding diary can be useful for monitoring urinary symptoms, the client’s description of urinary retention symptoms requires immediate assessment for bladder distention or obstruction, not just recording voiding patterns.

B: Obtaining a urine specimen is important if a urinary tract infection is suspected, but the symptoms described are more indicative of urinary retention, possibly due to prostate issues, which requires immediate physical assessment.
C:The client’s symptoms suggest urinary retention, which can be detected by palpating the suprapubic area for bladder distention. This is the most immediate assessment to determine if the client has retained urine in the bladder.

D: Cleansing the glans penis is important for hygiene and may prevent infections, but it does not address the underlying issue of bladder fullness and urinary retention.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits The nurse reviews the assessment findings along with the physician orders. Which immediate interventions would the nurse initiate? Select all that apply

Correct Answer is ["A","B","D","E","G"]

Explanation

An older adult male client arrives at the clinic reporting that his bladder always feels full. The client also reports a weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating the urine stream. Which action should the nurse implement?

Correct Answer is C

Explanation

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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?