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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale
Consuming large meals can exacerbate GERD symptoms. Smaller, more frequent meals are recommended to reduce the volume of food in the stomach at any one time, thereby reducing the pressure on the lower esophageal sphincter.
Choice B rationale
Identifying and avoiding foods that cause discomfort is a key strategy in managing GERD. Foods that commonly trigger GERD symptoms include fatty foods, spicy foods, acidic foods, and caffeine.
Choice C rationale

Using pillows to elevate the head and upper body during sleep can help prevent nighttime GERD symptoms. Gravity helps keep stomach acid in the stomach, reducing the chance of it flowing back into the esophagus.
Choice D rationale
Lying down after a meal can exacerbate GERD symptoms. It is recommended to wait at least three hours after eating before lying down.

A. Elevating the patient’s legs on two pillows B. Positioning the patient on the right side C. Keeping the patient in a high Fowler’s position D. Ambulating the patient twice each shift

Correct Answer is B

Explanation

Choice A rationale
Elevating the patient’s legs on two pillows is not typically a necessary action after a liver biopsy. This position does not directly aid in the recovery or prevention of complications related to a liver biopsy.
Choice B rationale
Positioning the patient on the right side after a liver biopsy is a common nursing intervention. This position applies pressure to the liver biopsy site, which can help minimize bleeding and facilitate clot formation at the biopsy site.
Choice C rationale
Keeping the patient in a high Fowler’s position is not typically recommended after a liver biopsy. This position does not provide direct benefits in terms of recovery or prevention of complications from a liver biopsy.
Choice D rationale

Ambulating the patient twice each shift is not typically recommended immediately after a liver biopsy. Rest is usually advised to allow the liver tissue to heal and to minimize the risk of bleeding.

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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?

Nursing Test Bank

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