A client with pancreatitis complains of severe epigastric pain, so the nurse administers a prescribed narcotic analgesic. Ten minutes later, the client insists on sitting up and leaning forward. Which intervention should the nurse implement?
Encourage rest until the analgesic becomes effective.
Raise head of bed until at a 90 degree angle.
Place bed in a reverse Trendelenburg position.
Position bedside table so the client can lean across it.
The Correct Answer is D
Choice A: Encourage rest until the analgesic becomes effective. This is not the best intervention, as it does not address the client's preference or comfort level. The analgesic may take some time to relieve the pain, and forcing the client to lie down may increase the pressure on the pancreas and worsen the pain.
Choice B: Raise head of bed until at a 90 degree angle. This is not the best intervention, as it does not address the client's preference or comfort level. Raising the head of bed may help reduce abdominal distension and improve breathing, but it may not relieve the pain as much as leaning forward.
Choice C: Place bed in a reverse Trendelenburg position. This is not the best intervention, as it does not address the client's preference or comfort level. Placing the bed in a reverse Trendelenburg position may help shift the abdominal organs away from the pancreas and reduce inflammation, but it may not relieve the pain as much as leaning forward.
Choice D: Position bedside table so the client can lean across it. This is the best intervention, as it addresses the client's preference and comfort level. Leaning forward may help decrease the tension on the pancreas and relieve the pain. The bedside table can provide support and stability for the client while sitting up.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: Measuring urine output daily is not a specific statement for the nurse to include, as this is a general recommendation for all clients with urinary catheters and does not address the potential complications of a suprapubic catheter. This is a distractor choice.
Choice B: Observing urine color and clarity is not a relevant statement for the nurse to include, as this does not reflect the condition of the suprapubic catheter or its insertion site. This is another distractor choice.
Choice C: Inspecting genital area for signs of infection is an important statement for the nurse to include, as this can help detect and prevent urinary tract infection, peritonitis, or abscess formation, which are common risks associated with suprapubic catheters. Therefore, this is the correct choice.
Choice D: Palpating flank area for tenderness is not a necessary statement for the nurse to include, as this is not an accurate or reliable method to assess for kidney function or damage, which are unlikely to occur with a suprapubic catheter. This is another distractor choice.
Correct Answer is D
Explanation
Choice A: Securing chest tube to the stretcher for transport is a good practice, but it is not the most important action. The chest tube should be secured to prevent accidental dislodgement or kinking, but it does not affect the function of the chest tube or the drainage system.
Choice B: Administering PRN pain medication prior to transport is a compassionate action, but it is not the most important action. The client may experience pain due to the chest tube, the intubation, or the underlying condition, but pain relief is not a priority over maintaining adequate ventilation and drainage.
Choice C: Marking the amount of chest drainage on the container is a useful action, but it is not the most important action. The amount of chest drainage should be recorded and reported to monitor the client's status and detect any complications, such as hemorrhage or infection, but it does not affect the immediate function of the chest tube or the drainage system.
Choice D: Keeping the chest tube container below the site of insertion is the most important action for the nurse to take. The chest tube container should be kept below the level of the client's chest to maintain a gravity-dependent pressure gradient that allows air and fluid to drain from the pleural space. If the container is raised above the site of insertion, it can cause backflow of air or fluid into the pleural space, which can compromise ventilation and cause tension pneumothorax.

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