A nurse is planning care for a client who has a new diagnosis of acute pancreatitis. Which of the following interventions should the nurse include in the plan of care?
Place the client in a supine position.
Administer antihypertensive medications.
Monitor the client for hypercalcemia.
Maintain the client on NPO status.
The Correct Answer is D
D. NPO status is typically implemented in the initial management of acute pancreatitis to rest the pancreas and reduce pancreatic enzyme secretion, which can exacerbate inflammation and tissue damage. Nutritional support may be gradually reintroduced once the client's condition stabilizes and symptoms improve.
A. Placing the client in a supine position is not recommended for acute pancreatitis because it can exacerbate pain and discomfort.
B. The priority in acute pancreatitis is to address pain, manage complications such as fluid imbalances or infections, and support pancreatic rest.
C. Hypercalcemia can occur as a complication of acute pancreatitis due to calcium mobilization from damaged pancreatic cells. However, keeping the client NPO is priority.
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Related Questions
Correct Answer is C
Explanation
A. Bladder spasms are a common postoperative complication after TURP, and they are typically associated with the irritation of the bladder wall. Cold compresses may be helpful for reducing muscle spasms or swelling in other situations, but they are not typically effective for relieving bladder spasms specifically.
B. Securing the urinary catheter is important to prevent dislodgement and ensure proper drainage. However, securing it to the upper left quadrant of the abdomen is not a standard practice.
C. The appropriate response is often to irrigate the catheter to relieve the obstruction and restore normal flow. While 0.9% sodium chloride (normal saline) is typically used for irrigation, the term "intermittent" refers to manually irrigating the catheter at intervals to flush out any blockages, which is an appropriate approach when there is a concern about obstruction.
D. Encouraging the client to urinate every 2 hours is not feasible or necessary in this situation.
Correct Answer is C
Explanation
A. Monitoring of vital signs should be more frequent
B. This is an important infection control measure for immunocompromised clients. However, this is more about environmental control and may not directly address the specific isolation protocols regarding direct person-to-person transmission.
C. Wearing an N95 respirator may be recommended for direct care, especially if there is concern about exposure to airborne infections from the environment, staff, or visitors.
D. While disposable plates and utensils are generally preferred for infection control, this is not a specific intervention for protective isolation.
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