A client is being cared for in the emergency department (ED) with acute abdominal pain and a provisional diagnosis of pancreatitis. The nurse assesses the client and obtains the results from laboratory studies. Which information is most valuable in reporting the client’s status to the healthcare provider (HCP)?

Reports of chronic constipation and serum gastrin levels

Presence of bowel sounds and degree of abdominal pain

Severity of nausea and vomiting and serum amylase results

Serum Helicobacter pylori (H. pylori) antibody results and urine output amounts

Answer and Explanation

The Correct Answer is C

Choice A reason: Chronic constipation and gastrin levels are irrelevant to pancreatitis. Gastrin relates to gastric acid production, not pancreatic inflammation. Pancreatitis is confirmed by amylase/lipase elevation, and constipation does not reflect its severity, making this information less valuable for reporting.

Choice B reason: Bowel sounds and abdominal pain degree provide general data but are non-specific. Pancreatitis requires amylase/lipase levels for diagnosis, and nausea/vomiting severity better indicates clinical status, making this information secondary to laboratory confirmation and symptom severity.

Choice C reason: Severity of nausea and vomiting and serum amylase results are critical, as elevated amylase confirms pancreatitis, and nausea/vomiting severity reflects disease impact. These directly inform the provider about pancreatic inflammation and clinical status, making this the most valuable information to report.

Choice D reason: H. pylori antibodies and urine output are unrelated to pancreatitis. H. pylori causes gastritis, and urine output monitors hydration, but amylase and nausea/vomiting directly address pancreatitis’s diagnosis and severity, making this information less relevant for immediate reporting.

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Correct Answer is C

Explanation

Choice A reason: A positive PPD skin test indicates TB exposure but not active disease, as it detects immune response to TB antigens. False positives occur in vaccinated or previously exposed individuals, making it insufficient to confirm active TB, requiring sputum culture for definitive diagnosis.

Choice B reason: Chest x-ray or CT shows lung abnormalities suggestive of TB, like cavitary lesions, but is not confirmatory. Imaging supports diagnosis but cannot identify Mycobacterium tuberculosis, making sputum culture the gold standard for confirming active infection, as imaging lacks specificity.

Choice C reason: Sputum culture positive for Mycobacterium tuberculosis confirms TB, as it directly isolates the pathogen. This test identifies active infection with high specificity, distinguishing TB from other lung diseases, making it the definitive diagnostic tool to review for accurate diagnosis and treatment.

Choice D reason: Hemoccult test on sputum detects blood, indicating hemoptysis, a TB symptom, but not the pathogen. It does not confirm TB, as bleeding can occur in other conditions, making sputum culture essential for identifying Mycobacterium tuberculosis and confirming the diagnosis.

A. Heart rate 120 beats/minute B. Respiratory rate 28 breaths/minute C. Oxygen saturation 90% D. Peak expiratory flow 60% of predicted

Correct Answer is A

Explanation

Choice A reason: A heart rate of 120 beats/minute requires immediate intervention, as albuterol, a beta-agonist, stimulates cardiac beta-1 receptors, causing tachycardia. In emphysema, repeated dosing increases cardiovascular stress, risking arrhythmias or ischemia, necessitating evaluation to adjust therapy or address potential overdose effects.

Choice B reason: Respiratory rate of 28 breaths/minute is elevated but expected in emphysema with dyspnea. Albuterol aims to reduce bronchospasm, and this rate does not indicate immediate danger compared to tachycardia, which poses a cardiovascular risk, making it less urgent.

Choice C reason: Oxygen saturation of 90% is low but common in emphysema exacerbations. Albuterol improves airflow, and supplemental oxygen may address hypoxia. While concerning, this is less immediately life-threatening than tachycardia, which indicates potential albuterol toxicity, requiring urgent intervention.

Choice D reason: Peak expiratory flow at 60% reflects airflow limitation in emphysema, improved by albuterol. While low, it is not as urgent as tachycardia, which signals cardiovascular strain from repeated albuterol doses, posing a greater immediate risk to the client’s stability.

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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

A client with emphysema is reporting a difficulty in breathing and exhibiting an 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?

Correct Answer is A

Explanation

The nurse is caring for a client who is taking diclofenac for rheumatoid arthritis. During a clinic visit, the client appears pale and reports increasing fatigue. Which of the client’s serum laboratory values is most important for the nurse to review?

The nurse is caring for a client with emphysema who is mildly dyspneic after ambulation. Which instruction should the nurse provide to the client to improve gas exchange?

A client with open-angle glaucoma asks the nurse how long the prescribed eye drops will need to be used. Which response made by the nurse is accurate?

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 psoriasis returns to the clinic reporting the persistence of several silvery, scaly areas on the elbows and palms that frequently burn and sometimes bleed. Which prescription should the nurse teach the client to use for the skin condition?

An adult client is admitted with AIDS and oral candidiasis manifested by several painful mouth ulcers. The nurse delegates oral care to the unlicensed assistive personnel (UAP) and discusses how to assist the client. Which instruction should the nurse provide the UAP?

An older adult female client is hospitalized with a fractured femur. During a routine nursing assessment, she repeatedly asks the nurse to “speak up” so that she can hear the questions. Which action is best for the nurse to take?