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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "I'll wear sandals in warm weather":
While wearing sandals in warm weather can be comfortable, it may not provide adequate protection for the feet, especially for individuals with diabetes. Closed, protective shoes are generally recommended to prevent injuries.
B. "I'll put lotion between my toes after drying my feet":
Applying lotion between the toes can create a moist environment, which may increase the risk of fungal infections. It is generally advisable to keep the skin between the toes dry to prevent infections.
C. "I'll check my feet every day for sores and bruises":
This statement is correct. Regular foot checks are crucial for individuals with diabetes to identify any signs of sores, bruises, or other abnormalities early. Early detection and prompt treatment can help prevent complications.
D. "I’ll soak my feet in cool water every night before I go to bed":
Soaking the feet in cool water is generally not recommended, as it can lead to maceration of the skin and increase the risk of fungal infections. Daily inspection and proper hygiene are more important aspects of foot care.
Correct Answer is C
Explanation
A. Instruct the client that they can lift over 20 lbs:
Lifting heavy objects should be avoided postoperatively to prevent strain on the surgical site. The specific weight restriction may vary, but lifting heavy objects is generally discouraged.
B. Offer the client ice cream postoperatively:
While offering ice cream may be a comforting measure, it is not a specific action related to the recovery from a laparoscopic cholecystectomy.
C. Encourage ambulation once fully awake:
This is the correct action. Encouraging ambulation helps prevent complications such as blood clots and promotes recovery after laparoscopic surgery. Early mobility is generally encouraged unless contraindicated for specific reasons.
D. Place the client in a supine position postoperatively:
The position of the client postoperatively depends on the specific surgical procedure and the surgeon's preferences. However, placing the client in a supine position alone is not a comprehensive postoperative care action.
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