which action should the nurse implement first for a client admitted with acute pancreatitis
Logo

Nursing Elites

HESI RN

HESI 799 RN Exit Exam Quizlet

1. What is the first action the nurse should implement for a client admitted with acute pancreatitis?

Correct answer: C

Rationale: Placing the client on NPO status is the priority action for a client with acute pancreatitis. This step is crucial to rest the pancreas, prevent pancreatic stimulation, and decrease enzyme production. By withholding oral intake, the digestive system is given a chance to rest and recover. Administering intravenous fluids may be necessary but should come after placing the client on NPO status. Pain medication can be administered once the client is stabilized. Assessing the client's abdomen for distention is important but is not the initial priority in managing acute pancreatitis.

2. One day after abdominal surgery, an obese client complains of pain and heaviness in the right calf. What action should the nurse implement?

Correct answer: A

Rationale: The correct action for the nurse to implement is to observe for unilateral swelling. Unilateral swelling could indicate a deep vein thrombosis (DVT), which is a serious complication that requires immediate assessment. Administering pain medication or applying warm compress may not address the underlying cause of the symptoms. Notifying the healthcare provider should be done after assessing and identifying the issue of unilateral swelling.

3. A male client with rheumatoid arthritis is scheduled for a procedure in the morning. The procedure cannot be completed due to early morning stiffness. Which intervention should the nurse implement?

Correct answer: A

Rationale: A warm shower can help alleviate stiffness, allowing the client to be more comfortable and mobile before the procedure. This intervention promotes increased comfort and mobility, which may help the client proceed with the procedure later in the day. Administering anti-inflammatory medication (Choice B) may be helpful but may take time to be effective, while range-of-motion exercises (Choice C) may be challenging for the client due to stiffness. Rescheduling the procedure (Choice D) does not address the immediate need to alleviate stiffness.

4. The nurse is caring for a client with a tracheostomy who has thick, tenacious secretions. Which assessment finding requires immediate intervention?

Correct answer: C

Rationale: Mucous plugging of the tracheostomy tube is the most concerning assessment finding in a client with a tracheostomy. It can lead to airway obstruction, which requires immediate intervention to ensure the client's airway remains patent. Crepitus around the tracheostomy site may indicate subcutaneous emphysema but is not as urgent as a blocked airway. A dry and cracked tracheostomy site may indicate poor skin integrity but does not pose an immediate threat to the client's airway. Yellowing of the skin around the tracheostomy site could suggest a localized infection, but it is not as critical as a potential airway obstruction caused by mucous plugging.

5. A client with end-stage renal disease (ESRD) is scheduled for hemodialysis. Which assessment finding should be reported to the healthcare provider immediately?

Correct answer: C

Rationale: The correct answer is C. A fever of 100.4°F is most concerning in a client with ESRD scheduled for hemodialysis as it may indicate an underlying infection, which can lead to serious complications in this population. Elevated body temperature can be a sign of sepsis, which requires immediate attention to prevent further deterioration. Reporting this finding promptly allows for timely intervention. Choices A, B, and D are within normal ranges and do not pose an immediate threat to the client's well-being in the context of preparing for hemodialysis.

Similar Questions

A client with chronic heart failure is receiving furosemide (Lasix). Which laboratory value requires immediate intervention?
A client with cirrhosis is admitted with jaundice and ascites. Which assessment finding is most concerning?
A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with an exacerbation. Which laboratory value should be monitored closely?
A client with newly diagnosed peptic ulcer disease is being taught about lifestyle modifications. Which client statement indicates that further teaching is needed?
A client with a history of myocardial infarction is admitted with chest pain. Which diagnostic test should the nurse anticipate preparing the client for first?

Access More Features

HESI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses