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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Pancrelipase may be prescribed to aid in digestion in chronic pancreatitis but is not typically used in the acute phase.
B) While ambulation may be encouraged as tolerated, it is not a specific prescription for acute pancreatitis.
C) Pantoprazole, a proton pump inhibitor, is often prescribed in acute pancreatitis to reduce gastric acid secretion, thereby reducing pancreatic stimulation and promoting healing.
D) In acute pancreatitis, dietary intake is typically restricted initially, often starting with nothing by mouth (NPO) and progressing to a clear liquid diet as tolerated; a low-residue diet is usually introduced at a later stage.
Correct Answer is B
Explanation
A) Bradycardia is not typically associated with hepatic encephalopathy.
B) Asterixis is a characteristic finding in hepatic encephalopathy, known as "flapping tremor," indicating neuromuscular irritability due to elevated blood ammonia levels.
C) Fever is not a common direct symptom of hepatic encephalopathy.
D) Melena indicates gastrointestinal bleeding, which while possible in liver disease, is not specific to hepatic encephalopathy.
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