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.

Assist the client to a side-lying position.

Provide oral hygiene.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Withholding oral fluids and food is the priority because it reduces pancreatic stimulation and decreases the secretion of pancreatic enzymes, preventing further autodigestion and inflammation of the pancreas.

Choice B rationale

Auscultating the client's lungs is important to check for complications such as pleural effusion or atelectasis, but it is not the immediate priority after pain management.

Choice C rationale

Assisting the client to a side-lying position can help with comfort and may ease breathing, but it does not directly address the underlying issue of pancreatic inflammation.

Choice D rationale

Providing oral hygiene is essential for overall care but does not impact the acute management of pancreatitis.

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Correct Answer is D

Explanation

Choice A rationale

Metabolic acidosis is characterized by a low pH and decreased HCO₃ levels, not increased PaCO₂.

Choice B rationale

Metabolic alkalosis presents with an elevated pH and increased HCO₃ levels, which do not match the given values.

Choice C rationale

Respiratory alkalosis is indicated by a high pH and decreased PaCO₂, opposite of the provided values.

Choice D rationale

Respiratory acidosis is identified by a low pH, elevated PaCO₂, and normal HCO₃, aligning with the provided values.

A. Temperature 36.1°C (97.0°F). B. Weight loss. C. Oliguria. D. Insomnia.

Correct Answer is C

Explanation

Choice A rationale

Temperature of 36.1°C (97.0°F) is below normal range and not indicative of organ rejection. Organ rejection often presents with elevated temperature due to the inflammatory response of the immune system attacking the transplanted organ.

Choice B rationale

Weight loss is not a common sign of acute organ rejection. Usually, fluid retention and associated weight gain can occur due to decreased kidney function.

Choice C rationale

Oliguria (reduced urine output) is a primary sign of kidney transplant rejection. It indicates that the transplanted kidney is not functioning properly, which is a critical indicator of rejection.

Choice D rationale

Insomnia is not typically associated with organ rejection. It can be related to stress or other factors but is not a direct sign of rejection.

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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?

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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?