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 D

Explanation

A. Applying heat may be indicated later, but the first action should be to address the infiltration.

B. Documenting the delay is important but not the immediate priority.

C. Starting a new IV site is necessary for continued medication administration but should be done after addressing the infiltration.

D. Removing the infiltrated IV catheter is the first priority to prevent further tissue damage and start appropriate treatment for infiltration.

Correct Answer is []

Explanation

Alcohol withdrawal syndrome often presents with symptoms such as tremors, palpitations, and agitation, and can escalate to severe symptoms including hallucinations and seizures.

Assessing for hallucinations is important because it helps in identifying more severe withdrawal symptoms that may require intervention.

Implementing seizure precautions is critical as withdrawal seizures can be life-threatening.

Monitoring pulse and blood pressure helps evaluate the client’s physiological response to withdrawal and the effectiveness of interventions.

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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

Before administering an IV antibiotic, the nurse observes that the skin above the client's IV site is cool, swollen, and painful to touch. Which action should the nurse implement first?

Correct Answer is D

Explanation

Patient Data Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Correct Answer is []

Explanation

After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take next?

Patient Data Exhibits The nurse reviews the prescriptions and assessment data. Click to indicate which interventions could help reduce symptoms if added to the plan of care. Each row must have one response option selected.

An older adult client is brought to the clinic for Increased confusion over the past three days and presents with a draining wound on the right leg. Which assessment is most important for the nurse to obtain?