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.

Answer and Explanation

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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Correct Answer is D

Explanation

D. A thrill is a palpable vibration or buzzing sensation felt over the graft site, caused by turbulent blood flow. In the context of an arteriovenous graft, a palpable thrill is typically considered a positive finding, indicating adequate circulation through the graft. It suggests that blood is flowing smoothly from the arterial to the venous side of the graft.
A. The presence of a bruit is typically considered a positive finding, indicating adequate blood flow through the graft. Therefore, the absence of a bruit may indicate inadequate circulation or a potential complication such as graft occlusion or stenosis.
B. Normal blood pressure is not a specific indicator of the adequacy of circulation through an arteriovenous graft.
C. A dilated appearance of the graft may suggest venous hypertension or increased pressure within the graft. While this could indicate adequate blood flow, it may also suggest problems such as venous stenosis or thrombosis, which can impede circulation through the graft.

A. Use moisturizing lotion while massaging the client's bony prominences. B. Instruct the client to sit on a rubber ring when seated in a chair. C. Place pillows between the client's knees when in a side-lying position. D. Raise the head of the client's bed to a 90° angle.

Correct Answer is C

Explanation

C. Placing pillows between the client's knees when in a side-lying position helps maintain proper alignment of the hips and prevents the affected leg from crossing over the midline, which could lead to muscle
contractures or discomfort. It also helps prevent pressure on bony prominences and reduces the risk of skin breakdown.
A. Keeping the bony prominences too moist could lead to increased risk of skin breakdown.
B. This is not recommended as it could exacerbate muscle weakness or discomfort on the affected side and may not provide adequate support for proper alignment.
D. Raising the head of the bed to a 90° angle is not typically indicated for clients with hemiplegia. It may increase the risk of aspiration

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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