Recognize Cues
Which assessment finding is most concerning?
BP 92/58 mmHg — indicates potential hypovolemia from fluid shifts.
What is the most likely priority problem?
Acute pain related to inflammation.
Which diagnosis has highest priority?
Risk for shock due to fluid volume deficit.
What is the first action for severe pain?
Administer prescribed opioid (e.g., morphine).
Which finding shows improvement?
Pain relief, tolerating clear liquids, normal amylase/lipase.
Which lab values confirm the diagnosis?
Elevated amylase and lipase — hallmark of pancreatitis.
What does a falling urine output with dry mucous membranes suggest?
Hypovolemia — third-spacing and fluid loss.
Pain relief is essential, but which intervention must precede opioid administration?
Assess vital signs and monitor respiratory status.
What is the rationale for maintaining the patient NPO?
To minimize pancreatic enzyme stimulation.
What indicates effective fluid resuscitation?
Stable BP, HR <100, urine output >30 mL/hr.
The nurse notes muscle twitching and tingling. Which electrolyte level explains this?
Low calcium (7.4 mg/dL) — hypocalcemia related to fat saponification.
Which complication should the nurse suspect if the abdomen becomes rigid and distended?
Peritonitis or pancreatic necrosis.
A nurse suspects sepsis. What cue best supports this?
Fever and increasing WBC count.
What IV fluids are typically initiated?
Lactated Ringer’s solution for volume expansion.
What patient statement shows correct understanding of teaching?
“I’ll avoid alcohol completely and eat low-fat meals.”
Which patient history detail supports the cause?
Chronic alcohol use — major etiologic factor for pancreatitis.
If the patient develops confusion, what lab should be reassessed first?
Calcium — severe hypocalcemia can cause neuromuscular irritability and confusion.
Which patient report requires immediate follow-up: nausea, mild pain, or decreasing urine output?
Decreasing urine output — indicates worsening hypovolemia.
Which position provides the most comfort?
Side-lying with HOB elevated or knee-chest position.
What does the absence of Trousseau’s or Chvostek’s sign signify?
Resolved hypocalcemia.
The patient complains of worsening abdominal pain after eating. What does this indicate?
Pancreatic stimulation by food — rest the pancreas (NPO).
What pattern in vitals would show possible systemic inflammatory response (SIRS)?
Tachycardia + hypotension + mild fever.
What condition becomes priority if lipase continues to rise after aggressive fluid therapy?
Pancreatic necrosis — requires rapid intervention.
Which medication reduces gastric acid secretion and pancreatic stimulation?
PPI (pantoprazole) or H2 blocker (famotidine).
Which finding suggests complications have resolved?
Normal vital signs, resolved pain, no distention, stable labs.