A nurse is caring for a client diagnosed with acute pancreatitis. After treating the client's pain, which of the following should the nurse address as the priority intervention?
Provide oral hygiene.
Assist the client to a side-lying position.
Auscultate the client's lungs.
Withhold oral fluids and food.
The Correct Answer is D
A. Provide oral hygiene.
Providing oral hygiene is important for the client's comfort and overall well-being. However, in the context of acute pancreatitis, the immediate priority is to address the gastrointestinal symptoms and prevent further pancreatic stimulation.
B. Assist the client to a side-lying position.
Assisting the client to a side-lying position can be beneficial for comfort and may help prevent complications such as aspiration. However, it is not the immediate priority after treating the pain. Withholding oral fluids and food takes precedence in the initial management of acute pancreatitis.
C. Auscultate the client's lungs.
Auscultating the client's lungs is a routine nursing assessment and is important for respiratory monitoring. However, in the context of acute pancreatitis, the primary focus is on addressing gastrointestinal symptoms, and respiratory assessment becomes more critical if respiratory distress is suspected.
D. Withhold oral fluids and food.
Withholding oral fluids and food is the priority intervention after treating the pain in acute pancreatitis. This is done to reduce pancreatic stimulation, allowing the pancreas to rest and recover. NPO (nothing by mouth) status is often initiated in the early management of acute pancreatitis.
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Related Questions
Correct Answer is D
Explanation
A. Avoiding eating at fast food restaurants is not a specific preventive measure for hepatitis A transmission. The primary mode of transmission for hepatitis A is through the fecal-oral route, often due to contaminated food or water.
B. Avoiding serving raw foods is a reasonable precaution as raw or undercooked shellfish and contaminated fruits and vegetables can be a source of hepatitis A transmission. However, practicing effective hand hygiene is a more general and fundamental preventive measure.
C. Wearing barrier protection during vaginal intercourse is not directly related to the prevention of hepatitis A. Hepatitis A is primarily transmitted through the fecal-oral route, and sexual transmission is not a common mode for this virus.
D. Practicing effective hand hygiene is a key strategy for preventing the transmission of hepatitis A. Proper handwashing with soap and water, especially after using the bathroom and before handling food, can help reduce the risk of contamination and transmission of the virus.
Correct Answer is B
Explanation
A. Lactulose is not used to decrease potassium levels. It is a laxative that works by drawing water into the colon, softening stools and promoting bowel movements.
B. Lactulose is used to decrease ammonia levels in clients with cirrhosis. Ammonia is a byproduct of protein metabolism, and when the liver is compromised, it may not effectively convert ammonia into urea, leading to elevated ammonia levels in the bloodstream. Lactulose helps reduce ammonia absorption in the colon.
C. Lactulose does not decrease glucose levels significantly. It is not primarily used as an antidiabetic medication.
D. Lactulose does not affect bicarbonate levels significantly. It primarily targets ammonia reduction in clients with cirrhosis.
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