A nurse is contributing to the care plan for a patient who has acute pancreatitis.
Which of the following interventions should the nurse include?
Monitor peripheral pulses every 8 hours
Measure urine output every 4 hours
Maintain NPO status
Ambulate the patient three times daily
The Correct Answer is C
Choice A rationale
Monitoring peripheral pulses every 8 hours is not typically a priority in the care plan for a patient with acute pancreatitis. While cardiovascular monitoring is important in all patients, it is not specifically related to the management of acute pancreatitis.
Choice B rationale
Measuring urine output every 4 hours can be important in assessing fluid balance and kidney function, but it is not the primary intervention in the care plan for a patient with acute pancreatitis.
Choice C rationale
Maintaining NPO (nothing by mouth) status is a key intervention in the management of acute pancreatitis. This helps to rest the pancreas and reduce the production of digestive enzymes.
Choice D rationale
Ambulating the patient three times daily is generally a good practice for postoperative recovery, but it is not specific to the care of a patient with acute pancreatitis. In the acute phase of pancreatitis, rest is often recommended.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Increasing fluid and fiber intake is one of the first steps in managing constipation in elderly patients. Fiber adds bulk to the stool and makes it easier to pass, while fluids help keep the stool soft.
Choice B rationale
While avoiding gas-producing foods may help with some digestive issues, it’s not specifically helpful for managing constipation.
Choice C rationale
While a stool softener can help relieve constipation, it’s usually considered after dietary changes have been tried without success.
Choice D rationale
Physical activity can help stimulate bowel movements and is often recommended as part of constipation management. However, it’s not the first step, and its effectiveness can depend on the individual’s overall health and mobility.
Question 31.
Correct Answer is D
Explanation
Choice A rationale
Chlorhexidine is an antiseptic that is used for cleaning the skin or the hands and helps to prevent infections caused by bacteria. However, it is not the recommended cleansing agent for hand hygiene in a Clostridium difficile infection.
Choice B rationale
Alcohol-based antiseptics are commonly used for hand hygiene in healthcare settings. However, they are not effective against Clostridium difficile spores.
Choice C rationale
Povidone-iodine is an antiseptic used for skin disinfection before and after surgery. It may not be effective against Clostridium difficile spores.
Choice D rationale
Soap and water are recommended for hand hygiene when caring for a patient with a Clostridium difficile infection. This is because soap and water are effective in removing C. difficile spores from hands.
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