A nurse is gathering information from a patient who is experiencing a perforation of a peptic ulcer. Which of the following symptoms should the nurse anticipate?

Choice A rationale
While allowing grieving is an important aspect of holistic care for a client with esophageal cancer, it is not the priority nursing intervention. Emotional support and counseling are crucial, but they do not take precedence over interventions aimed at maintaining the client’s physical health.
Choice B rationale
Preventing aspiration is the priority nursing intervention for a client with esophageal cancer. Aspiration, or the inhalation of food, stomach acid, or saliva into the lungs, can lead to pneumonia and other serious complications. Therefore, measures to prevent aspiration, such as educating the client on safe swallowing techniques, elevating the head of the bed during meals, and monitoring for signs of aspiration, are crucial.
Choice C rationale
Managing pain relief is an important aspect of care for a client with esophageal cancer, but it is not the priority nursing intervention. Pain management strategies, such as administering prescribed analgesics and providing comfort measures, are part of a comprehensive care plan

but do not take precedence over interventions aimed at preventing immediate life-threatening complications like aspiration.
Choice D rationale
Maintaining nutritional intake is an important aspect of care for a client with esophageal cancer, but it is not the priority nursing intervention. Nutritional support, such as providing a balanced diet, encouraging small frequent meals, and possibly arranging for a consultation with a dietitian, are important but do not take precedence over interventions aimed at preventing immediate life-threatening complications like aspiration.

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.