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 this scenario, administering the prescribed pain medication (Option B) should be the first nursing intervention for a client with acute pancreatitis experiencing severe abdominal pain. Pain management is crucial in this situation to provide relief, improve comfort, and support the client's overall well-being. Uncontrolled pain can lead to complications and hinder the client's recovery process. Assessing the client's bowel sounds (Option A) is important in the overall care of a client with pancreatitis, but it is not the priority when the client is in severe pain. Administering pain medication takes precedence to address the immediate discomfort and distress. Encouraging the client to sit upright (Option C) may be beneficial in some cases to promote comfort and aid digestion, but in the presence of severe pain, this intervention may exacerbate the client's discomfort. Providing clear fluids to the client (Option D) is important for hydration and nutritional support in pancreatitis management, but it does not address the client's immediate need for pain relief. In an educational context, understanding the prioritization of nursing interventions based on the client's condition and needs is essential for providing safe and effective care. Pain management is a fundamental aspect of nursing care, especially in acute conditions like pancreatitis, where timely intervention can significantly impact the client's outcomes.

Correct Answer: A

Rationale: In caring for a client with COPD receiving oxygen therapy, a pulse oximetry reading of 94% indicates improving oxygenation. Oxygen saturation levels above 92-94% are considered optimal for most patients. This assessment finding suggests that the therapy is effectively increasing the client's oxygen levels. Option B, an increase in heart rate, is not indicative of improved oxygenation but can be a sign of stress or other factors influencing heart function. Option C, an increase in respiratory rate, may indicate the client is working harder to breathe, which is not a sign of improved oxygenation. Option D, increased energy levels, can be subjective and may not directly correlate with improved oxygenation. Educationally, understanding the significance of pulse oximetry readings in assessing oxygenation status is crucial for nurses caring for clients with respiratory conditions. It allows for prompt intervention and evaluation of the effectiveness of oxygen therapy, leading to better patient outcomes.

Correct Answer: D

Rationale: Intravenous fluids are essential for rehydrating an infant who is likely suffering from dehydration due to projectile vomiting. This condition, commonly related to pyloric stenosis, causes rapid fluid loss. Oral rehydration methods might not be sufficient or appropriate for such a young infant, especially if vomiting persists. IV therapy ensures controlled and adequate fluid replacement to stabilize the child.

Correct Answer: D

Rationale: In this scenario, the correct assessment the nurse should obtain to evaluate the therapeutic response of a client receiving lactulose for hepatic encephalopathy is the "Level of consciousness" (Option D). This is crucial because hepatic encephalopathy is a condition characterized by altered mental status and consciousness due to liver dysfunction. Lactulose is commonly used to reduce ammonia levels in hepatic encephalopathy by promoting its excretion in the stool. Assessing the client's level of consciousness is vital as it directly reflects the effectiveness of the treatment. Improvement in consciousness levels indicates a positive response to the lactulose therapy. On the other hand, if the client's level of consciousness does not improve or worsens, it may indicate the need for further interventions or adjustments in the treatment plan. Percussion of the abdomen (Option A) is not directly related to evaluating the therapeutic response to lactulose in hepatic encephalopathy. Blood glucose level (Option B) and serum electrolytes (Option C) are important assessments in various conditions but are not specifically indicated to evaluate the response to lactulose in hepatic encephalopathy. Educationally, understanding the rationale behind selecting the correct assessment helps nurses develop critical thinking skills in assessing and managing clients with hepatic encephalopathy. It reinforces the importance of tailored assessments based on the client's condition and the treatment being provided, ultimately leading to improved patient outcomes.

Correct Answer: D

Rationale: The correct answer is D) Antihypertensives and anticholinergics. In this case, the client's symptoms of eye dryness, itching, and excessive tearing are likely due to the side effects of antihypertensive and anticholinergic medications. Antihypertensive medications can cause dryness of mucous membranes, including the eyes, as a common side effect. Anticholinergic medications, which inhibit the action of acetylcholine in the body, can lead to dryness of the eyes and mouth, as well as itching. Option A) Antiinfectives and antidepressants are not typically associated with symptoms of eye dryness, itching, and excessive tearing. Option B) Anticoagulants and antihistamines do not commonly cause the symptoms described by the client. Option C) Antiretrovirals and antivirals are not known to produce the specific symptoms of eye dryness, itching, and excessive tearing. In an educational context, understanding the potential side effects of medications is crucial for healthcare professionals to provide safe and effective care to older adult clients. This knowledge helps in assessing and managing medication-related symptoms and ensuring the overall well-being of the clients.