A client is admitted to the medical unit with acute pancreatitis. While planning care for this client, the nurse will include which of the following interventions? (Select all that apply).
Administer antiemetics as needed.
Administer analgesics as needed.
NPO (nothing by mouth) until pain-free.
Monitor blood glucose and provide insulin as needed.
Side-lying or fetal position.
Monitor hydration status.
Correct Answer : A,B,C,D,F
Choice A: Administer antiemetics as needed Reason: Acute pancreatitis often causes severe nausea and vomiting. Antiemetics are administered to control these symptoms and prevent further complications such as dehydration and electrolyte imbalance.
Choice B: Administer analgesics as needed Reason: Pain management is a crucial part of the treatment for acute pancreatitis. The condition can cause severe abdominal pain, and analgesics are administered to provide relief.
Choice C: NPO (nothing by mouth) until pain-free Reason: The goal in treating acute pancreatitis is to allow the pancreas to rest and recover from the inflammation3. Keeping the patient NPO (nothing by mouth) helps achieve this by reducing the stimulation and workload of the pancreas.
Choice D: Monitor blood glucose and provide insulin as needed Reason: Acute pancreatitis can affect the pancreas’ ability to produce insulin, leading to elevated blood glucose levels. Therefore, monitoring blood glucose levels and administering insulin as needed is an important part of the management plan.
Choice E: Side-lying or fetal position Reason: While the side-lying or fetal position might help some patients with abdominal pain, it is not a standard intervention for acute pancreatitis. Therefore, this option is not correct.
Choice F: Monitor hydration status Reason: Patients with acute pancreatitis are at risk of dehydration due to symptoms like vomiting and decreased oral intake. Monitoring hydration status is crucial to ensure appropriate fluid replacement.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: A distended bladder is a common cause of autonomic dysreflexia. It can trigger an exaggerated response from the autonomic nervous system, leading to a rapid increase in blood pressure. This is because the full bladder sends signals to the spinal cord, which then attempts to send signals to the brain. However, due to the injury, these signals cannot pass through, resulting in a reflex that increases blood pressure.
Choice B reason: While a severe headache is a symptom of autonomic dysreflexia, it is not a cause. The headache results from the body's response to a triggering stimulus, such as a distended bladder, which leads to the high blood pressure characteristic of autonomic dysreflexia.
Choice C reason: Nasal congestion is not typically a cause of autonomic dysreflexia. The condition is usually triggered by a noxious stimulus below the level of the spinal cord injury, such as a full bladder or bowel, skin irritation, or other types of physical discomfort.
Choice D reason: Elevated blood pressure is a symptom, not a cause, of autonomic dysreflexia. The condition itself causes a sudden spike in blood pressure due to an uncontrolled reflex sympathetic discharge in response to a triggering stimulus below the level of the injury.
Correct Answer is B
Explanation
Choice A reason: The GFR does not recover during the oliguric phase; instead, it is typically reduced, reflecting impaired kidney function.
Choice B reason: Urine output of less than 400 mL per 24 hours is characteristic of the oliguric phase of AKI. This phase can last from 1 to 7 days after kidney injury and is a crucial time for monitoring and managing the patient's fluid and electrolyte balance.
Choice C reason: BUN and creatinine levels do not decrease during the oliguric phase. They usually increase due to reduced kidney function and the inability to excrete these waste products.
Choice D reason: Renal function is not reestablished during the oliguric phase. This phase is part of the course of AKI where renal function is at its lowest, and recovery has not yet begun.
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