The nurse receives report for a client with acute pancreatitis on hospital day 2: NPO with NGT to low intermittent suction, VS: 110/60, 99.2°F-97- 22, 0.9% NS infusing at 125 mL/hour, and IV antibiotics have been started. Chart review reveals the following current laboratory results. Which is a priority for the nurse to report to the healthcare provider?
WBC 10,000/mm3 (5,000-10,000 mm3)
Serum potassium 3.5 mEq/L (3.5-5.0 mEq/L)
Serum albumin 4.8 g/dL (3.5-5 g/dL)
Lipase 900 u/L (20-180 u/L)
The Correct Answer is D
A) While an elevated WBC count may indicate infection, it is not unexpected in acute pancreatitis.
B) Serum potassium within normal range does not require immediate intervention.
C) Serum albumin within normal range does not require immediate intervention.
D) Lipase levels significantly elevated above the normal range indicate ongoing pancreatic inflammation and may require intervention or adjustment of treatment.
Nursing Test Bank
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Related Questions
Correct Answer is B
Explanation
A) Monitoring intake and output (I&O) is crucial for understanding the patient's fluid balance, especially after 24 hours of vomiting, which could lead to dehydration. However, it is important for fluid balance but not the immediate next step.
B) Checking blood pressure can provide immediate information on the patient's hemodynamic status and potential hypovolemia due to fluid loss; thus, it should be assessed immediately.
C) Assessing pain level is important for comfort, but stabilization of vital signs takes precedence.
D) Measuring oxygen saturation is useful but less critical than assessing for potential hypotension due to dehydration.
Correct Answer is B
Explanation
A) Monitoring blood glucose is more relevant for diabetic care.
B) A sodium diet is appropriate for managing fluid retention associated with liver disease.
C) Bedrest may be prescribed but not as specific to the management of fluid retention.
D) Insertion of an indwelling urinary catheter is not a standard intervention without additional justification.
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