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 C
Explanation
A. Storing unopened bottles of insulin in the freezer is incorrect. Insulin should be stored in the refrigerator, and freezing can damage the insulin.
B. Having a morning blood glucose level between 200 and 230 is too high. The target range for fasting blood glucose is generally lower, and elevated levels may indicate the need for adjustment in insulin or other medications.
C. Eating a snack half an hour before playing soccer is a correct understanding. This helps prevent hypoglycemia during physical activity. Physical activity can lower blood glucose levels, and a pre-activity snack can provide additional carbohydrates to prevent low blood sugar.
D. Not taking regular insulin when sick is incorrect. In fact, insulin needs may increase during illness, and it is usually recommended to continue taking insulin even when sick. Adjustments to the insulin regimen may be needed under the guidance of healthcare providers.
Correct Answer is D
Explanation
A. COPD (Chronic Obstructive Pulmonary Disease) is not directly associated with acute pancreatitis. The common risk factors for acute pancreatitis include gallstones, alcohol use, and certain medications.
B. Hypolipidemia (low blood lipid levels) is not a typical factor associated with acute pancreatitis. Elevated levels of lipids in the blood (hyperlipidemia) can be a risk factor, but hypolipidemia is not commonly linked to pancreatitis.
C. Diabetes mellitus, while not a direct cause of acute pancreatitis, can be associated with an increased risk. Uncontrolled diabetes may contribute to the development of pancreatitis, but it is not a primary risk factor.
D. Gallstones are a significant risk factor for acute pancreatitis. Gallstones can obstruct the pancreatic duct, leading to inflammation and damage to the pancreas. This obstruction is one of the common causes of acute pancreatitis.
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