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) Weight loss is a common symptom of chronic pancreatitis due to malabsorption and decreased appetite.
B) Cool, clammy skin is not typically associated with chronic pancreatitis; it may indicate other conditions such as shock or hypotension.
C) Bruising on the flank is not a typical finding in chronic pancreatitis; it may suggest trauma or other underlying conditions.
D) Ascites, the accumulation of fluid in the abdominal cavity, is more commonly associated with advanced liver disease rather than chronic pancreatitis.
Correct Answer is B
Explanation
A) Pancreatic enzymes are typically used to aid in digestion rather than pain control in acute pancreatitis.
B) Decompression of the gastrointestinal tract through nasogastric suction can help reduce pancreatic stimulation and alleviate pain in acute pancreatitis.
C) While ambulation may help prevent complications, it is not directly related to pain control in acute pancreatitis.
D) A clear liquid diet may be initiated once the acute phase has resolved, but it does not directly contribute to pain control.
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