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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "Wear compression stockings daily":
Compression stockings are not directly related to preventing the complications of retinopathy and nephropathy in diabetes. They are more commonly recommended for managing conditions like venous insufficiency and preventing blood clots.
B. "Have an eye examination once per year":
While regular eye examinations are important for monitoring and early detection of diabetic retinopathy, maintaining stable blood glucose levels is more directly related to preventing the progression of retinopathy.
C. "Maintain stable blood glucose levels":
This is the correct instruction. Stable blood glucose levels are crucial in preventing and minimizing the long-term complications of diabetes, including retinopathy (damage to the retina) and nephropathy (kidney damage). Consistent blood glucose control is key to reducing the risk of complications.
D. "Examine your feet carefully every day":
Daily foot examinations are essential for preventing diabetic foot complications, including ulcers and infections. While important for overall diabetes management, foot care is not specifically directed at preventing retinopathy and nephropathy.
Correct Answer is A
Explanation
A. Regular insulin:
Regular insulin, also known as short-acting insulin, is commonly used in the initial management of diabetic ketoacidosis. It has a relatively rapid onset of action, making it suitable for addressing the acute and severe nature of DKA.
B. Insulin detemir:
Insulin detemir is a long-acting insulin analog. It is not the preferred choice for addressing the acute insulin needs in DKA; instead, it is used for basal insulin requirements in the maintenance phase of diabetes management.
C. Insulin glargine:
Insulin glargine is a long-acting insulin analog used for basal insulin coverage. Like insulin detemir, it is not the first choice for addressing the acute insulin needs in the initial treatment of DKA.
D. NPH insulin:
NPH (Neutral Protamine Hagedorn) insulin is an intermediate-acting insulin. While it has a role in diabetes management, it is not the preferred choice for the initial treatment of DKA. NPH insulin has a slower onset and longer duration compared to regular insulin.
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