When providing care for a client hospitalized with acute pancreatitis who has acute abdominal pain, which nursing interventions would be most appropriate for this client? Select all that apply.
Place the client in a side-lying position.
Administer hydromorphone for pain as prescribed.
Obtain daily weights.
Maintain a high-calorie, high-protein diet.
Monitor the client's respiratory status.
Correct Answer : A,B,E
Choice A reason: Placing the client in a side-lying position is beneficial for comfort and can help alleviate pain in clients with acute pancreatitis. This position can reduce pressure on the pancreas and improve circulation, helping to manage pain and discomfort effectively.
Choice B reason: Administering hydromorphone for pain as prescribed is essential in managing acute abdominal pain associated with acute pancreatitis. Pain control is a priority in the care of these clients because unmanaged pain can lead to increased stress and further complications. Hydromorphone, a potent opioid analgesic, helps to effectively manage severe pain.
Choice C reason: Obtaining daily weights is important for monitoring a client's nutritional status and fluid balance, but it is not directly related to the immediate management of acute abdominal pain in acute pancreatitis. While it is a relevant intervention, it is not as critical as the other measures listed.
Choice D reason: Maintaining a high-calorie, high-protein diet is not appropriate for a client with acute pancreatitis. In fact, clients with acute pancreatitis are often placed on a nil-per-os (NPO) status initially to rest the pancreas and reduce enzyme secretion. Once the inflammation subsides, a low-fat, bland diet may be introduced gradually.
Choice E reason: Monitoring the client's respiratory status is crucial because clients with acute pancreatitis are at risk for respiratory complications, such as pleural effusion, acute respiratory distress syndrome (ARDS), or atelectasis. Close monitoring ensures early detection and intervention for any respiratory issues that may arise.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: The regulation of water balance by the kidneys involves maintaining the appropriate volume and concentration of body fluids. By taking daily weights, nurses can assess fluid retention or loss, while monitoring intake and output (I&O) helps track fluid balance. Specific gravity measures the concentration of urine, which provides information about the kidneys' ability to concentrate or dilute urine. These interventions directly relate to the kidneys' role in regulating water balance.
Choice B reason: Regulation of acid-base balance by the kidneys involves maintaining the proper pH levels in the blood through excretion or retention of hydrogen ions and bicarbonate. While important, this function is not the primary focus of interventions like daily weights, I&O, and specific gravity monitoring, which are more related to water balance.
Choice C reason: The regulation of blood pressure by the kidneys is achieved through the renin-angiotensin-aldosterone system, which controls blood volume and systemic vascular resistance. Although fluid balance can indirectly affect blood pressure, the specific interventions mentioned are more directly related to water balance than blood pressure regulation.
Choice D reason: Regulation of metabolic wastes involves the kidneys filtering and excreting waste products from the blood. This function is vital for overall health, but interventions like daily weights, I&O, and specific gravity monitoring are more focused on assessing fluid balance rather than directly measuring waste elimination.
Correct Answer is D
Explanation
Choice A reason: An increased albumin level, while noteworthy, is not typically an urgent finding to communicate immediately following paracentesis. Albumin levels can fluctuate for various reasons, and elevated levels do not generally indicate a critical issue requiring immediate intervention.
Choice B reason: A normal platelet count is a good sign, indicating that the patient has an adequate number of platelets for blood clotting and wound healing. This finding does not indicate an urgent need to notify the healthcare provider immediately.
Choice C reason: A 2-cm area of serous drainage on the dressing is relatively small and expected after a procedure like paracentesis. It suggests that the site is draining some fluid, which is normal post-procedure. While it should be monitored, it does not necessitate urgent communication unless it worsens or there are signs of infection.
Choice D reason: A heart rate of 122 beats/min is tachycardia and can indicate several potential complications, including hypovolemia (low blood volume) due to the large fluid removal, infection, or other stressors on the patient's body. This finding is the most critical to communicate to the healthcare provider promptly as it may require immediate intervention to address the underlying cause and stabilize the patient.
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