A nurse is contributing to the plan of care for a client who has acute pancreatitis. Which of the following interventions should the nurse include?
Monitor peripheral pulses every 8 hr.
Ambulate the client three times daily.
Maintain NPO status.
Measure urine output every 4 hr.
The Correct Answer is C
Choice A rationale
Monitoring peripheral pulses every 8 hours is not a specific intervention for a client who has acute pancreatitis. While it is important to monitor peripheral pulses as part of overall patient assessment, it does not directly address the needs of a patient with acute pancreatitis.
Choice B rationale
Ambulating the client three times daily is not a specific intervention for a client who has acute pancreatitis. While physical activity is generally beneficial for overall health, it does not directly address the needs of a patient with acute pancreatitis, especially during an acute attack.
Choice C rationale
Maintaining NPO (nothing by mouth) status is a common intervention for a client who has acute pancreatitis. This allows the pancreas to rest and recover, reducing inflammation and pain.
Choice D rationale
Measuring urine output every 4 hours is not a specific intervention for a client who has acute pancreatitis. While it is important to monitor urine output as part of overall patient assessment, it does not directly address the needs of a patient with acute pancreatitis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
It is a good practice to change the batteries in smoke detectors annually to ensure they are working properly. This statement does not indicate a need for further instruction.
Choice B rationale
Using a walker when going upstairs can be dangerous due to the risk of falls. It is recommended that individuals use handrails or assistance when navigating stairs, not a walker. This statement indicates that the client needs further instruction.
Choice C rationale
Leaving a night light on can help prevent falls by providing visibility during the night. This statement does not indicate a need for further instruction.
Choice D rationale
Installing grab bars in the bathroom, especially near the toilet and in the shower, can provide support and prevent falls. This statement does not indicate a need for further instruction.
Correct Answer is B
Explanation
Choice A rationale
While it’s important to prepare for a barium swallow test, maintaining a clear liquid diet 24 hours before the test is not typically required.
Choice B rationale
Drinking plenty of fluids after the test is indeed a correct instruction. The barium used in the test can cause constipation or impacted stool if it does not pass out of the body. Drinking ample fluids helps flush the contrast from the gastrointestinal system.
Choice C rationale
While it’s true that the stool may be discolored after a barium swallow test, it’s more likely to be lighter or white, not black.
Choice D rationale
The barium swallow test does not involve the injection of any dye that would cause a warm feeling. This sensation is more commonly associated with the injection of contrast dye in other types of imaging tests, not a barium swallow.
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