When assessing a client for acute pancreatitis, which of the following symptoms will the nurse observe?

Correct Answer: C

Rationale: The correct answer is C: Rapid breathing and pulse rate. In acute pancreatitis, inflammation of the pancreas can lead to systemic complications, including respiratory distress and tachycardia. This occurs due to the release of inflammatory mediators affecting the respiratory and cardiovascular systems. Increased thirst and urination (Choice A) are more indicative of diabetes or renal issues. Hypertension and nausea (Choice B) are not typical symptoms of acute pancreatitis. Frothy, foul-smelling stools (Choice D) are more likely linked to malabsorption disorders rather than acute pancreatitis. Rapid breathing and pulse rate are key signs that indicate the severity of the condition and the need for prompt intervention.

Correct Answer: A

Rationale: The correct answer is A: Prevention of aspiration. This is essential in tube feeding to avoid the risk of food or liquid entering the lungs, causing aspiration pneumonia. Nursing interventions for this include ensuring proper positioning during and after feeding, checking residual volumes before each feeding, and using the appropriate tube size and placement. Incorrect Choices: B: Prevention of diarrhea - Diarrhea is not directly related to tube feeding complications, but rather to factors such as infection, medication side effects, or underlying conditions. C: Maintenance of tube patency - While important, this focuses on ensuring the tube remains clear and functional, not directly related to preventing aspiration. D: Maintenance of tube placement - Ensuring proper tube placement is crucial for effective feeding but does not directly address the risk of aspiration.

Correct Answer: A

Rationale: Step 1: The priority is to administer fluids to rehydrate the patient. Step 2: Intravenous fluids are not mentioned, so the nurse should start with oral fluids. Step 3: Option A is the most appropriate choice as it addresses the need for fluid intake to promote rehydration. Step 4: Water (Option B) lacks electrolytes that aid in rehydration. Step 5: Hot tea (Option C) may irritate the stomach and not provide adequate hydration. Step 6: Gatorade (Option D) contains electrolytes but may be too heavy for initial rehydration.

Correct Answer: C

Rationale: The correct answer is C: Projectile vomiting of undigested food. In a patient with a perforated peptic ulcer, the sudden opening in the stomach lining allows food to pass into the abdominal cavity, leading to projectile vomiting of undigested food. This symptom is a classic sign of a perforation and requires immediate medical attention. Choice A is incorrect because vomiting of bright-red blood is more indicative of upper gastrointestinal bleeding, not a perforation. Choice B is incorrect as vomiting undigested food is more common in conditions like gastroparesis, not perforated ulcers. Choice D is incorrect as severe upper abdominal pain and back pain are symptoms of a perforation but not as specific as projectile vomiting of undigested food.

Correct Answer: C

Rationale: The correct answer is C: IV fluid replacement. IV fluids are essential in managing peritonitis to maintain hydration and electrolyte balance. It helps to support the patient's circulation and prevent shock. Peritoneal lavage (choice A) is not typically used in the treatment of peritonitis. Peritoneal dialysis (choice B) is used for kidney failure, not peritonitis. Increased oral fluid intake (choice D) may not be sufficient in cases of peritonitis where IV fluids are needed for rapid rehydration and support.