A client diagnosed with pancreatitis reports severe epigastric pain. After administering a narcotic analgesic, the client insists on Tip sitting up and leaning forward. Which action should the nurse implement?

Provide a bedside table for client to lean across.

Place bed in the reverse Trendelenburg position.

Encourage bed rest until analgesic takes effect.

Raise the head of the bed to a 90 degree angle.

Answer and Explanation

The Correct Answer is A

A. Provide a bedside table for the client to lean across. Clients with acute pancreatitis often experience severe epigastric pain that radiates to the back. Leaning forward helps reduce pressure on the inflamed pancreas and relieves pain by minimizing peritoneal irritation. Providing a bedside table allows the client to rest in a comfortable, supported position, improving pain management without additional interventions.
B. Place bed in the reverse Trendelenburg position. Reverse Trendelenburg elevates the head and lowers the feet, which does not specifically relieve pain associated with pancreatitis. The client instinctively leans forward for relief, and adjusting the bed position would not provide the same benefit. This intervention does not directly address the underlying cause of discomfort.
C. Encourage bed rest until analgesic takes effect. Although pain control is essential, keeping the client in a supine or bedrest position can increase abdominal pressure and worsen discomfort. Allowing the client to assume a comfortable position enhances the effectiveness of analgesics and prevents unnecessary distress. Pain relief strategies should focus on both pharmacologic and positioning interventions.
D. Raise the head of the bed to a 90-degree angle. Elevating the head of the bed can improve breathing and reduce reflux, but it does not provide the same pressure relief as leaning forward. Sitting upright without forward support does not effectively relieve peritoneal irritation from pancreatic inflammation. Providing a bedside table supports proper positioning and enhances comfort.

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Correct Answer is A

Explanation

A. Decreased cardiac output. Central venous pressure (CVP), also called right atrial pressure (RAP), reflects right ventricular preload and overall fluid status. An increasing CVP indicates fluid overload or impaired right ventricular function, both of which can lead to decreased cardiac output. Conditions such as right heart failure, pulmonary hypertension, or excessive fluid resuscitation can cause elevated CVP, reducing the heart’s ability to pump effectively and leading to poor systemic circulation.
B. Ineffective airway clearance. Airway clearance is not directly related to CVP measurements. While severe pulmonary conditions like ARDS or COPD can contribute to cardiac strain and right heart failure, the primary mechanism for rising CVP is cardiac dysfunction or fluid overload, not airway obstruction.
C. Ineffective peripheral tissue perfusion. Although decreased cardiac output can impair tissue perfusion, this choice is too broad. Increased CVP specifically reflects right-sided heart function and preload, making decreased cardiac output the more precise diagnosis related to the pathophysiologic mechanism.
D. Deficient fluid volume. A low CVP is associated with hypovolemia and fluid deficits, while an increasing CVP suggests fluid overload, heart failure, or venous congestion. Deficient fluid volume would cause a downward trend in CVP, not an increase.

A. Oxygenate before suctioning. B. Auscultate bilateral breath sounds. C. Firmly secure the ETT in place. D. Suction the ETT every 2 hours.

Correct Answer is C

Explanation

A. Oxygenate before suctioning. Pre-oxygenation before suctioning is essential to prevent hypoxia and bradycardia, but it does not directly ensure that the ETT remains in the correct position. This is a general airway management guideline rather than a specific intervention to maintain ETT placement.
B. Auscultate bilateral breath sounds. Auscultation is important for ongoing assessment of lung sounds and oxygenation but does not physically prevent tube displacement. While listening for equal breath sounds helps detect tube migration or mainstem bronchus intubation, it does not secure the ETT in place.
C. Firmly secure the ETT in place. After proper ETT placement is confirmed with a chest x-ray, securing the tube with adhesive tape or a commercial ETT holder prevents displacement. Unintentional extubation or tube migration can lead to hypoxia, respiratory distress, or esophageal intubation, making proper tube fixation a priority intervention.
D. Suction the ETT every 2 hours. Routine suctioning is not recommended unless there are indications such as visible secretions, high airway pressures, or decreased oxygenation. Frequent, unnecessary suctioning can cause mucosal trauma, hypoxia, and bradycardia and does not help maintain ETT placement.

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A client diagnosed with pancreatitis reports severe epigastric pain. After administering a narcotic analgesic, the client insists on Tip sitting up and leaning forward. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is evaluating a client's central venous pressure (CVP) also called right atrial pressure (RAP) readings that are trending upwards. Which nursing problem is supported by the pathophysiologic mechanism most likely causing the increases?

Correct Answer is A

Explanation

After intubating a client, correct placement of the endotracheal tube (ETT) is confirmed with a chest x-ray. Which intervention should the nurse implement to ensure that the ETT placement is maintained?

Correct Answer is C

Explanation

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