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.
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Related Questions
Correct Answer is C
Explanation
Choice A rationale
Carcinoembryonic Antigen (CEA) is a protein used as a tumor marker, particularly for cancers of the gastrointestinal tract. It is not directly related to volume depletion caused by gastrointestinal illnesses.
Choice B rationale
B12 level is important for nerve function and the formation of red blood cells. It is not directly related to volume depletion caused by gastrointestinal illnesses.
Choice C rationale
Electrolyte imbalance is the correct answer. Gastrointestinal illnesses often cause symptoms such as vomiting and diarrhea, which can lead to significant loss of fluids and electrolytes.
Monitoring electrolyte levels is crucial in these cases to prevent complications related to volume depletion.
Choice D rationale
Hemoglobin level is an indicator of the amount of oxygen-carrying protein in the blood. While it is an important lab value, it is not the most relevant in the context of volume depletion due to gastrointestinal illnesses.
Correct Answer is B
Explanation
Choice A rationale
Folate, also known as vitamin B9, is essential for many functions in the body, including cell growth and division, amino acid metabolism, and the formation of white and red blood cells. However, it is not the treatment for pernicious anemia.
Choice B rationale
Pernicious anemia is a condition where the body cannot absorb enough vitamin B12 in the small intestine, causing a drop in red blood cells. Treatment for pernicious anemia involves vitamin B12 injections or oral supplementation to restore levels to an optimal range, followed by continued injections or oral medications to maintain these levels.
Choice C rationale
Vitamin C is essential for the growth, development, and repair of all body tissues. It’s involved in many body functions, including the formation of collagen, absorption of iron, the immune system, wound healing, and the maintenance of cartilage, bones, and teeth. However, it is not the treatment for pernicious anemia.
Choice D rationale
Iron is a mineral that our bodies need for many functions. For example, iron is part of hemoglobin, a protein which carries oxygen from our lungs throughout our bodies. However, it is not the treatment for pernicious anemia.
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