Three days after a cholecystectomy for cholelithiasis, a female client reports having persistent upper abdominal pain that radiates to her back. She has vomited three times in the last 12 hours and has a temperature of 101.8° F. (38.7° C). Serum amylase and lipase are twice the normal value. Based on these findings, the nurse should observe the client for which pathophysiological condition?

Acute pancreatitis.

Biliary duct obstruction.

Surgical site infection.

Hepatorenal failure.

Answer and Explanation

The Correct Answer is A

A. The symptoms of persistent upper abdominal pain radiating to the back, elevated serum amylase and lipase levels, vomiting, and fever suggest acute pancreatitis, which can occur after cholecystectomy due to potential injury to the pancreas or bile duct obstruction.
B. While biliary duct obstruction can occur postoperatively, the significantly elevated amylase and lipase levels, along with the described symptoms, more strongly indicate pancreatitis.
C. Surgical site infection typically presents with localized symptoms rather than systemic symptoms like elevated amylase and lipase.
D. Hepatorenal failure is unlikely to present with these specific gastrointestinal symptoms and enzyme elevations.

Nursing Test Bank

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Correct Answer is C

Explanation

A. A hemoccult test on sputum is used to detect blood and is not specific to TB.
B. A positive PPD skin test indicates exposure to TB but does not confirm active disease; further testing is required.
C. A sputum culture positive for Mycobacterium tuberculosis is the definitive test for confirming active tuberculosis, as it isolates the organism.
D. A chest x-ray or CT can suggest the presence of TB but does not provide a definitive diagnosis; culture is necessary for confirmation.

A. Perform hand hygiene B. Brush the client's teeth C. Check the skin around the face D. Identify the client using 2 client identifiers E. Assess respiratory function F. Don gloves G. Determine if the client needs to go to the bathroom

Correct Answer is ["A","C","D","E"]

Explanation

A. Performing hand hygiene is crucial to prevent the spread of infection before any patient interaction or procedure.
B. Brushing the client’s teeth is not necessary before applying an oxygen mask and does not pertain to immediate care.
C. Checking the skin around the face is important to ensure there are no irritations or breakdowns that could affect the mask's fit and the patient's comfort.
D. Identifying the client using 2 identifiers is a critical safety step to ensure the correct patient receives the intended care.
E. Assessing respiratory function is important to determine the severity of the client’s condition and the appropriate oxygen delivery method.
F. Donning gloves is not required for applying a simple face mask unless there is potential for contact with blood or bodily fluids.
G. Determining if the client needs to go to the bathroom is not directly related to applying the face mask and should be assessed but is not critical before mask application.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is admitting a client with possible tuberculosis (TB). The client is placed in a private room with airborne precautions pending diagnostic test results. Which diagnostic test should the nurse review to confirm the diagnosis of TB?

Correct Answer is C

Explanation

Exhibits The nurse is preparing to set up the oxygen administration and apply the simple face mask. Which should the nurse do before applying the face mask? Select that apply.

Correct Answer is ["A","C","D","E"]

Explanation

A client with symptoms of influenza that started the previous day asks the clinic nurse about taking oseltamivir to treat the infection. Which response should the nurse provide?

A client with chronic cirrhosis has esophageal varices. It is most important for the nurse to monitor the client for the onset of which problem?

A client with myasthenia gravis receives a new prescription for pyridostigmine. Which information should the nurse obtain prior to administering the medication?

A client with emphysema is reporting difficulty in breathing and exhibiting audible wheezing. The nurse administers albuterol as prescribed for the third time within the last 12 hours. Which assessment finding warrants immediate intervention by the nurse?

A client diagnosed with chronic obstructive pulmonary disease (COPD) is given a new prescription for tiotropium via an inhalation device. Which statement indicates that the client understands the instructions for using this medication?

Exhibits Which of the following does the nurse anticipate the healthcare provider to prescribe during morning rounds? Select 4 findings.

A client has been administered lactulose for several days. Which therapeutic response should the nurse expect for a client with hepatic encephalopathy?

Which approach is best for the nurse to use when directing a client with Huntington's disease to the hospital cafeteria?