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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Culturing for sensitive organisms is essential in identifying the causative agent of the infection indicated by the purulent drainage, guiding appropriate antibiotic therapy.
B. Blood pH level is not directly relevant to assessing wound drainage or infection status.
C. C-reactive protein (CRP) can indicate inflammation but is not specific enough to provide immediate information regarding the infection at the wound site.
D. Serum blood glucose level is more relevant for assessing the client's overall metabolic status and risk for infections rather than directly correlating with the purulent drainage observed.
Correct Answer is B
Explanation
A. Performing postural drainage immediately after meals can lead to discomfort or aspiration; it is usually advised to wait at least one hour after eating.
B. This statement is correct, as postural drainage involves positioning the client in various positions to help mobilize secretions from different lung segments, typically five positions are used.
C. Shallow and fast breathing is not recommended during postural drainage; deep breathing is encouraged to facilitate effective clearance of secretions.
D. Obtaining an arterial blood gas (ABG) is not routinely necessary before postural drainage; the focus is on mobilizing secretions.
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