A nurse is caring for a client who has acute pancreatitis. After treating the client’s pain, which of the following should the nurse address as the priority intervention?
Withhold oral fluids and food.
Auscultate the client’s lungs.
Provide oral hygiene.
Assist the client to a side-lying position.
The Correct Answer is A
Choice A reason: Withhold oral fluids and food
Withholding oral fluids and food (NPO status) is a critical intervention for clients with acute pancreatitis. This helps to rest the pancreas by reducing the stimulation of pancreatic enzyme secretion, which can exacerbate inflammation and pain. Maintaining NPO status is essential to prevent further pancreatic damage and to allow the pancreas to heal.
Choice B reason: Auscultate the client’s lungs
While auscultating the lungs is an important part of the overall assessment, it is not the immediate priority after pain management in acute pancreatitis. Respiratory complications can occur, but the primary focus should be on managing the pancreatic inflammation and preventing further damage.
Choice C reason: Provide oral hygiene
Providing oral hygiene is important for overall patient care, especially when the client is NPO. However, it is not the priority intervention immediately after pain management. The primary concern is to prevent further pancreatic stimulation and manage the inflammation.
Choice D reason: Assist the client to a side-lying position
Assisting the client to a side-lying position can help with comfort and may be beneficial in managing pain. However, it is not the priority intervention. The main focus should be on preventing further pancreatic stimulation by withholding oral intake.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: The procedure will be cancelled if the urinalysis indicates the presence of red blood cells
This statement is incorrect. The presence of red blood cells in the urine does not necessarily cancel an intravenous pyelogram (IVP). The test is often used to diagnose conditions that might cause blood in the urine, such as kidney stones or tumors. Therefore, this statement does not accurately reflect the procedure’s protocol.
Choice B reason: You will be able to resume your regular diet as soon as the test is complete
This statement is correct. After an IVP, clients can typically resume their regular diet unless otherwise instructed by their healthcare provider. However, this is not the most critical piece of information for the client to understand about the procedure.
Choice C reason: High-frequency sound waves will be used to identify renal system structures
This statement is incorrect. An IVP uses X-rays and a contrast dye to visualize the urinary tract, not high-frequency sound waves. High-frequency sound waves are used in ultrasound imaging, which is a different diagnostic procedure.
Choice D reason: After the procedure, you will be encouraged to drink plenty of fluids
This statement is correct and important. After an IVP, clients are encouraged to drink plenty of fluids to help flush the contrast dye out of their system and reduce the risk of kidney damage. This is a crucial part of post-procedure care and should be emphasized to the client.
Correct Answer is B
Explanation
Choice A reason: Discussing the visitation policy is important for the client’s overall hospital experience but does not directly relate to the prevention of postoperative complications. Visitation policies help manage the flow of visitors and ensure the client gets adequate rest, but they do not address specific postoperative risks.
Choice B reason: Instructing the client about the use of a sequential compression device is crucial for preventing deep vein thrombosis (DVT) and pulmonary embolism, which are common postoperative complications. Sequential compression devices (SCDs) help improve blood circulation in the legs, reducing the risk of blood clots forming during periods of immobility after surgery.
Choice C reason: Teaching the client how to use the PCA pump (patient-controlled analgesia) is important for pain management but does not directly prevent postoperative complications. Proper pain management can aid in recovery by allowing the client to move and breathe more effectively, but it is not a primary preventive measure for complications like DVT or infections.
Choice D reason: Reviewing the pain scale helps the client communicate their pain levels effectively, which is important for managing postoperative pain. However, like the PCA pump, it does not directly prevent complications. Effective pain management can contribute to overall recovery but is not a standalone preventive measure.
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