Upon assessment, Cullen’s sign is noted. What complication of acute pancreatitis would the nurse suspect that the client might have?

Choice A rationale

While pain management is important, maintaining the airway is the priority intervention for a client with deep partial- and full-thickness burns to the face, chest, abdomen, and upper arms. Burns to the face and chest can cause airway edema and compromise breathing.

Choice B rationale

Maintaining the airway is the priority intervention during the resuscitation phase of injury for a client with burns to the face, chest, abdomen, and upper arms. Airway edema can develop rapidly, and securing the airway is crucial to ensure adequate oxygenation and ventilation.

Choice C rationale

Inserting an indwelling urinary catheter is important for monitoring urine output and fluid balance, but it is not the priority intervention. Airway management takes precedence in this scenario.

Choice D rationale

Initiating fluid resuscitation is essential for managing burn shock and maintaining hemodynamic stability, but maintaining the airway is the priority intervention to ensure the client can breathe adequately.

Choice A rationale

Providing diversionary activities for the client can help distract them and reduce the likelihood of them pulling on their NG tube. Diversionary activities can include engaging the client in conversation, providing them with puzzles or games, or allowing them to watch television or listen to music. These activities can help occupy the client’s time and attention, reducing the need for restraints.

Choice B rationale

Assisting the client with toileting at frequent intervals can address any discomfort or need that may be causing the client to pull on their NG tube. Ensuring that the client is comfortable and their needs are met can reduce agitation and the likelihood of them pulling on the tube.

Choice C rationale

Involving the family in the client’s care can provide additional support and reassurance to the client. Family members can help calm the client and provide a familiar presence, which can reduce anxiety and the need for restraints.

Choice E rationale

Using an electronic bed alarm device can alert the nursing staff if the client attempts to get out of bed or pull on their NG tube. This allows for timely intervention without the need for physical restraints.