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
Acquired hemolytic anemia is a condition where the body destroys red blood cells faster than it can produce them, but it is not typically associated with the need for lifelong vitamin B12 supplementation following stomach surgery.
Choice B rationale
Pernicious anemia is a condition that can develop in patients who have had a large portion of their stomach surgically removed. This is because the stomach plays a crucial role in the absorption of vitamin B12. Without sufficient stomach tissue, the body may not be able to
absorb enough vitamin B12 from food, leading to a deficiency. Therefore, these patients often require lifelong vitamin B12 supplementation.
Choice C rationale
Iron-deficiency anemia is typically caused by a lack of iron in the diet, not a lack of vitamin B12. Therefore, patients with this condition would not typically require lifelong vitamin B12 supplementation following stomach surgery.
Choice D rationale
Sickle cell anemia is a genetic disorder that affects the shape and function of red blood cells. It is not typically associated with the need for lifelong vitamin B12 supplementation following stomach surgery.
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