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","D","E"]

Explanation

A. Giving the client 4 ounces of orange juice can quickly raise blood glucose levels if hypoglycemia is suspected.

B. Administering insulin is inappropriate without knowing the current blood glucose level, especially if hypoglycemia is suspected.

C. Diet carbonated soda does not contain sugar and will not help raise blood glucose levels.

D. Checking the client's fingerstick blood glucose is essential to determine if hypoglycemia is causing the symptoms.

E. Obtaining blood pressure and pulse rate is important to assess the client's overall condition and identify any additional complications.

A. Peripheral pulses present with full range of motion of both legs. B. History of vomiting at home for 3 days prior to surgery. C. Soft abdomen, absent bowel sounds, no bleeding on dressing. D. Declining to take ice chips despite reporting of dry mouth.

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.

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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

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

Explanation

Correct Answer is C

Explanation

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