When planning care for a client with acute pancreatitis, which nursing intervention has the highest priority?

Administer antiemetics as needed.

Withhold food and fluid intake.

Evaluate intake and output ratio.

Initiate IV fluid replacement.

Answer and Explanation

The Correct Answer is D

A. Administering antiemetics is important for symptom management but does not address the primary issue of fluid balance and pancreatic inflammation.

B. Withholding food and fluid intake is a necessary intervention for managing acute pancreatitis, but it is secondary to ensuring adequate fluid resuscitation.

C. Evaluating intake and output is important for monitoring fluid balance but is less critical than initiating fluid replacement.

D. Initiating IV fluid replacement is the highest priority as it addresses the risk of dehydration and maintains hemodynamic stability, which is crucial in acute pancreatitis management.

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Correct Answer is A

Explanation

A. Checking the femoral site for hematoma formation is crucial as the client’s pain at the groin insertion site could indicate bleeding or hematoma formation, which requires immediate attention.

B. Evaluating the IV insertion site is important but does not directly address the pain at the groin site.

C. Stimulating the client to take deep breaths helps with respiratory function but does not address the potential complications at the groin site.

D. Assessing distal lower extremity capillary refill is useful for overall circulation but is not the immediate concern in this situation.

A. Obtain serum creatinine levels daily. B. Monitor daily sodium intake. C. Ensure client takes a diuretic every morning. D. Measure ankle circumference.

Correct Answer is C

Explanation

A. Obtaining serum creatinine levels is important but not an immediate intervention.

B. Monitoring sodium intake is essential but not the first step in acute management.

C. Administering a diuretic can help manage the fluid retention and reduce blood pressure, addressing the immediate concern of fluid overload.

D. Measuring ankle circumference is part of monitoring fluid status but does not address the immediate need to reduce fluid overload.

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When planning care for a client with acute pancreatitis, which nursing intervention has the highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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