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 B
Explanation
Choice A rationale
While it’s important to ensure the feeding bag contains enough formula for the feeding period, it’s not recommended to fill the bag with more than 4-6 hours’ worth of formula at a time due to the risk of bacterial growth.
Choice B rationale
This is the correct answer. Flushing the gastrostomy tube with water every 4 hours helps maintain tube patency and hydrates the patient.
Choice C rationale
Changing the feeding bag and tubing every 72 hours is a common practice, but it’s not the most critical intervention in this scenario.
Choice D rationale
Keeping the head of the bed elevated at 30 to 45 degrees during feeding and for 1 to 2 hours afterward is recommended to minimize the risk of aspiration. However, 15 degrees may not be sufficient.
Correct Answer is A
Explanation
Choice A rationale
Hepatitis A is most likely contracted from contaminated food or water. Hepatitis A virus (HAV) is transmitted by the fecal-oral route via contaminated food or infected food handlers. This is different from Hepatitis B, C, and D which are most commonly transmitted via infected blood or body fluids.
Choice B rationale
Hepatitis B is not typically contracted from contaminated food. It is most commonly transmitted via infected blood or body fluids.
Choice C rationale
Hepatitis C is not typically contracted from contaminated food. It is most commonly transmitted via infected blood or body fluids.
Choice D rationale
Hepatitis D is not typically contracted from contaminated food. It is most commonly transmitted via infected blood or body fluids.
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