the nurse is caring for a client with acute pancreatitis who is reporting severe abdominal pain which nursing intervention should the nurse implement
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Nursing Elites

HESI RN

HESI RN Exit Exam Capstone

1. The nurse is caring for a client with acute pancreatitis who is reporting severe abdominal pain. Which nursing intervention should the nurse implement first?

Correct answer: B

Rationale: In a client with acute pancreatitis experiencing severe abdominal pain, the priority nursing intervention is to provide pain relief. Administering prescribed pain medication is essential to improve comfort and reduce pain, which can help stabilize the client's condition. Assessing bowel sounds (Choice A) may be necessary but is not the immediate priority over pain management. Encouraging the client to sit upright (Choice C) and providing clear fluids (Choice D) are not the primary interventions for addressing severe abdominal pain in acute pancreatitis.

2. A client with diabetes mellitus is experiencing diabetic ketoacidosis (DKA). What laboratory result should the nurse monitor closely?

Correct answer: B

Rationale: A blood glucose level of 320 mg/dL indicates the need for insulin to manage diabetic ketoacidosis.

3. While auscultating heart sounds, the nurse hears a swishing sound. How should this sound be documented?

Correct answer: B

Rationale: The correct answer is B: 'Murmur.' A murmur is a swishing sound heard during auscultation, typically caused by turbulent blood flow through the heart or valves. Choices C and D, 'S3 sound' and 'S4 sound,' refer to specific heart sounds associated with different cardiac conditions, not the general description of a swishing sound. Choice A, 'Heart murmur,' is redundant as 'murmur' alone is sufficient to describe the swishing sound heard.

4. During the admission assessment of a 3-year-old with bacterial meningitis and hydrocephalus, which assessment finding is evidence of increased intracranial pressure (ICP)?

Correct answer: D

Rationale: Sluggish and unequal pupillary responses are indicative of increased intracranial pressure (ICP) in a child with bacterial meningitis and hydrocephalus. This finding suggests that the optic nerve is being compressed due to increased ICP, causing a delay in pupillary reactions. Such a delay is a critical sign of worsening ICP and necessitates immediate intervention. Low blood pressure and increased respiratory rate can occur in various conditions but are less specific to increased ICP than sluggish and unequal pupillary responses, which directly reflect neurological compromise.

5. A toddler presenting with a history of intermittent skin rashes, hives, abdominal pain, and vomiting that occurs after ingesting milk products arrives at the clinic accompanied by the parents. Which type of testing should the nurse educate the toddler's family about?

Correct answer: D

Rationale: The correct answer is D, Serum immunoglobulin E (IgE) testing. This test can help diagnose food allergies, including milk protein allergies, in toddlers presenting with symptoms like skin rashes, hives, abdominal pain, and vomiting after consuming milk products. Skin allergy testing is used for allergies but may not be suitable for this age group due to developmental factors. Lactose intolerance, which is different from a milk allergy, is assessed through a lactose tolerance test, not IgE testing. A complete blood count (CBC) would not provide specific information related to food allergies.

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