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 C

Explanation

A. While the presence of peripheral pulses and full range of motion is important, it is typically included in the physical assessment findings and is less immediately relevant to postoperative status compared to other options.

B. The history of vomiting at home is part of the client’s medical history but is not immediately relevant to the postoperative status.

C. Information about the abdomen (soft, absent bowel sounds, no bleeding on dressing) is critical as it pertains directly to the surgical site and postoperative recovery.

D. Declining ice chips despite reporting a dry mouth is noteworthy but less critical than assessing the surgical site and abdominal status.

A. Assess for symmetrical chest movement. B. Obtain a portable chest x-ray to verify ETT location. C. Monitor ETT markings between 22 and 26 cm at teeth line. D. Check for capillary refill of 3 seconds or less. E. Auscultate for presence of bilateral breath sounds.

Correct Answer is ["A","B","E"]

Explanation

A. Assessing for symmetrical chest movement helps ensure that air is moving into both lungs, indicating proper placement of the ETT.

B. Obtaining a portable chest x-ray is a definitive method to verify ETT placement in the correct position within the trachea.

C. Monitoring ETT markings is useful for tracking tube displacement over time, but it does not confirm correct placement.

D. Checking capillary refill is not relevant for confirming ETT placement; it assesses peripheral circulation.

E. Auscultating for bilateral breath sounds confirms that air is reaching both lungs, which indicates correct placement of the ETT.

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

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A young adult is brought to the emergency department after taking a handful of drugs. The client is unresponsive, so an endotracheal tube (ETT) is inserted. How should the nurse determine if the ETT is correctly placed? Select all that apply.

Correct Answer is ["A","B","E"]

Explanation

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

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