Practice Question
The nurse cares for a client that presents with severe abdominal pain radiating to the back that occurred after drinking alcohol. The client reports vomiting does not relieve the pain. The client's blood pressure is 90/52, heart rate 128, and respiratory rate 36. What is the priority action by the nurse?
Answer Choices:
Correct Answer:
Start intravenous fluids.
Rationale:
🔷 The client’s symptoms (severe abdominal pain radiating to the back, vomiting, history of alcohol use) are classic signs of acute pancreatitis.
🔷 Hypotension (90/52), tachycardia (128), and tachypnea (36) indicate hypovolemia and systemic inflammatory response, which can progress to hypovolemic or septic shock.
🔷 Aggressive IV fluid resuscitation with isotonic fluids (e.g., lactated Ringer’s) is the priority to restore intravascular volume, prevent hypovolemic shock, and maintain organ perfusion.
🔷 Early fluid replacement also helps prevent pancreatic necrosis and multi-organ failure associated with severe pancreatitis.
🔷 Pain management is important but secondary to stabilizing hemodynamics and circulation (ABCs priority).
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This question is from RN Medical Surgical-Summer 2025 which contains 67 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: Examplify Exam(s)
- Domain: Medical-Surgical
- Answer Choices: 4