While assessing the client with acute pancreatitis the nurse notes the following: skin warm and dry with inelastic turgor, hypoactive bowel sounds, nausea and vomiting for 24 hours, and amber-colored urine. Which action would the nurse take next?
Monitor I&O
Check blood pressure
Assess pain level
Measure oxygen saturation
The Correct Answer is B
A) Monitoring intake and output (I&O) is crucial for understanding the patient's fluid balance, especially after 24 hours of vomiting, which could lead to dehydration. However, it is important for fluid balance but not the immediate next step.
B) Checking blood pressure can provide immediate information on the patient's hemodynamic status and potential hypovolemia due to fluid loss; thus, it should be assessed immediately.
C) Assessing pain level is important for comfort, but stabilization of vital signs takes precedence.
D) Measuring oxygen saturation is useful but less critical than assessing for potential hypotension due to dehydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Helps maintain muscle tone and promotes overall well-being without overstressing the body during recovery from hepatitis B.
B) Antibiotics are not effective against viruses like hepatitis B.
C) There is generally no need to restrict fluids in hepatitis B; adequate hydration supports overall health and liver function.
D) A high-fat diet is not recommended for liver disease; typically, a balanced, low-fat diet is more appropriate.
Correct Answer is B
Explanation
A) Ascites, the accumulation of fluid in the abdominal cavity, typically presents with weight gain rather than weight loss.
B) Ascites often accompanies peripheral edema, particularly in the lower extremities.
C) Ascites is not typically associated with flushed skin; rather, it may lead to pallor due to anemia or jaundice due to liver dysfunction.
D) Ascites is not directly associated with vomiting blood; hematemesis may indicate complications such as esophageal varices, which can occur in advanced liver disease.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.