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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A) Requesting a dietary consult is useful but not the most immediate action needed.

B) Ordering a 2 gram sodium restriction diet is important but not addressing the immediate issue of electrolyte imbalance.
C) Fluid restriction may be considered but not before addressing the electrolyte issues.
D) Holding the spironolactone and furosemide is the correct action, as administering these could exacerbate the existing hypokalemia and hyponatremia, increasing the risk of adverse effects.

A. Check blood glucose every 4 hours B. 2 gram sodium diet C. Bedrest D. Insert indwelling urinary catheter

Correct Answer is B

Explanation

A) Monitoring blood glucose is more relevant for diabetic care.

B) A sodium diet is appropriate for managing fluid retention associated with liver disease.
C) Bedrest may be prescribed but not as specific to the management of fluid retention.
D) Insertion of an indwelling urinary catheter is not a standard intervention without additional justification.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to administer spironolactone (Aldactone) and furosemide (Lasix) at 0900 to a client diagnosed with ascites. Review of 0600 laboratory results shows serum sodium 130 mEq/L (136-145 mEq/L) and potassium 3.1 mEq/L (3.5-5.0 mEq/L). Which action should the nurse take first?

Correct Answer is D

Explanation

The nurse is admitting a client with liver disease who presents with dyspnea, weight gain and abdominal distention. Which order would the nurse anticipate?

Correct Answer is B

Explanation

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