A 45-year-old female patient is admitted to the emergency department with severe abdominal pain, fever, and nausea. She reports that the pain started suddenly and has progressively worsened. The healthcare provider suspects peritonitis and orders immediate interventions.

Physical examination

On examination, the patient has a distended abdomen, guarding, and rebound tenderness.

Her vital signs are as follows:

Temperature 102.4°F (39.1°C), Heart rate 120 bpm, Blood pressure 90/60 mmHg, and Respiratory rate 24 breaths per minute.

Which of the following complications is the nurse's highest priority to monitor for in this patient?

Intestinal obstruction

Hypovolemic shock

Electrolyte imbalance

Sepsis

Answer and Explanation

The Correct Answer is B

A. Intestinal obstruction: While peritonitis can lead to intestinal obstruction, it is not the most immediate life-threatening complication compared to hypovolemic shock or sepsis.

B. Hypovolemic shock: This is a critical condition that can occur due to severe fluid loss, which might be a concern in peritonitis due to fluid shifts into the abdominal cavity. However, the patient’s signs of systemic infection (fever, elevated heart rate, low blood pressure) suggest that sepsis is a more imminent threat.

C. Electrolyte imbalance: Electrolyte imbalances are possible due to fluid loss, but they would be secondary to the more urgent concern of hypovolemic shock.

D. Sepsis: Sepsis is the highest priority due to the patient’s vital signs and symptoms indicating a systemic infection. Early recognition and treatment of sepsis are crucial to prevent organ failure and other severe complications.

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

Explanation

A. Frothy urine: Frothy urine is typically associated with proteinuria, seen in nephrotic syndrome, not pyelonephritis.

B. Hypertension: Hypertension can occur due to kidney inflammation and impaired function in pyelonephritis.

C. Fish-type urine odor: A foul or fishy-smelling urine odor is often associated with a urinary tract infection, including pyelonephritis.

D. Mental confusion: Mental confusion can occur in elderly patients with pyelonephritis due to systemic infection or sepsis.

E. Lower abdominal pain: Lower abdominal pain can occur with pyelonephritis due to infection in the urinary tract.

F. Weak urine stream: A weak urine stream is more characteristic of lower urinary tract issues, such as benign prostatic hyperplasia (BPH), rather than pyelonephritis.

A. Measure abdominal girth daily. B. Moisten the client's lips with lemon-glycerin swabs. C. Maintain the client in Fowler's position. D. Use sterile water to irrigate the nasogastric tube.

Correct Answer is A

Explanation

A. Measure abdominal girth daily. Measuring abdominal girth daily helps assess for changes in distention, which is important in monitoring the effectiveness of the decompression.

B. Moisten the client's lips with lemon-glycerin swabs: This is incorrect because lemon-glycerin swabs can dry the oral mucosa. Using plain water or normal saline swabs would be more appropriate.

C. Maintain the client in Fowler's position: This is appropriate as it helps promote drainage from the nasogastric tube and reduces the risk of aspiration.

D. Use sterile water to irrigate the nasogastric tube: Irrigation is typically done with normal saline to maintain electrolyte balance. Sterile water is not recommended for this purpose.

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Naxlex Comprehensive Predictor Exams

A nurse is gathering data on a client who was admitted with pyelonephritis. Which of the following manifestations should the nurse expect the client to be exhibiting? (Select All that Apply.)

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

Explanation

A nurse is contributing to the plan of care for a client who has an intestinal obstruction and is receiving continuous gastrointestinal decompression using a nasogastric tube. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is A

Explanation

A nurse is assessing an older adult client who has a urinary tract infection (UTI). Which of the following findings should the nurse identify as unique for this age group?

A nurse is reviewing medications for a client who has just been diagnosed with a small bowel obstruction. The nurse should withhold senna prescribed orally based on understanding of which of the following?

A female patient recently underwent a partial gastrectomy and is now presenting with symptoms of weakness, dizziness, and sweating, particularly after meals. Based on these symptoms, what is the most likely diagnosis?

When caring for older adult clients at a long-term care facility, which of the following assessments should the nurse prioritize when evaluating for the risk and presence of urinary retention? (Select all that apply.)

During the process of collecting a comprehensive medical history from a client who has been admitted with pyelonephritis, which of the following symptoms or historical details would the nurse most likely expect the client to report?

A patient undergoing chemotherapy reports painful oral ulcers, difficulty eating, and a metallic taste in the mouth. The nurse suspects stomatitis. Which nursing intervention is most appropriate for this patient?

A patient with Crohn's disease is being discharged from the hospital. The nurse is providing dietary teaching to the patient. Which of the following statements by the patient indicates a correct understanding of the dietary recommendations?

A female patient presents with right upper quadrant pain, nausea and vomiting. She has been diagnosed with acute cholecystitis. What is the most appropriate nursing action to alleviate her symptoms?