A nurse is caring for a client who is scheduled to have his alanine aminotransferase (ALT) level checked. The client asks the nurse to explain the laboratory test. Which of the following is an appropriate response by the nurse?

"This test is used to check how your kidneys are working."

"This test will indicate if you are at risk for developing blood clots."

"This test will provide information about the function of your liver."

"This test will determine if your heart is performing properly."

Answer and Explanation

The Correct Answer is C

Choice A reason:
ALT is not primarily used to check kidney function. Kidney function is typically assessed through other tests, such as blood urea nitrogen (BUN) and creatinine levels.
Choice B reason:
ALT is not used to assess the risk of blood clots. It is specifically related to liver function.
Choice C reason:
Alanine aminotransferase (ALT) is an enzyme found primarily in the liver. An elevated ALT level in the blood can indicate potential liver damage or disease, so the ALT test is used to assess the function of the liver.
Choice D reason:
ALT is not a test to determine heart performance. Heart function is evaluated using tests such as electrocardiograms (ECGs) or cardiac enzymes.

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Correct Answer is C

Explanation

Choice A reason:
Palpation can help assess for tenderness, rigidity, or masses in the abdomen, which might indicate infection, bleeding, or other complications. However, palpation could potentially worsen a condition such as an evisceration or dehiscence, or cause additional pain. Therefore, palpation should be done only after the visual inspection and with great caution in the presence of severe pain.
Choice B reason:
Percussion is useful for assessing the presence of gas, fluid, or solid masses in the abdomen. Resonance might indicate normal air-filled intestines, while dullness could suggest fluid or mass. However, percussion is not the first action in an acute setting of sudden severe pain because it does not provide immediate information that could be life-saving. It is a later step in the physical examination.
Choice C reason:
Visual inspection is the first step because it can quickly reveal critical signs such as swelling, distention, redness, or evidence of wound complications like dehiscence or evisceration. Identifying these signs early allows for rapid intervention, which could be life-saving. This is why exposing and inspecting the abdomen is the priority in the context of sudden severe pain following surgery.
Choice D reason:
Listening for bowel sounds can provide information about the function of the gastrointestinal system. Absence of bowel sounds might suggest a paralytic ileus, while hyperactive sounds could indicate a bowel obstruction. However, in the context of sudden, severe abdominal pain postoperatively, auscultation is not the first priority.

A. Notify the provider. B. Describe the surgery to the client. C. Provide brochures about the procedure. D. Complete an incident report.

Correct Answer is A

Explanation

Choice A reason:
The client has expressed a lack of understanding about the procedure, which indicates that they may not have received sufficient information or clarification. It is important to notify the provider so they can ensure the client fully understands the procedure before giving informed consent.
Choice B reason:
The nurse should provide basic information and answer questions within their scope, but detailed explanations about the procedure are best provided by the provider who is performing the surgery.
Choice C reason:
While brochures can be helpful, they do not replace the need for direct, clear communication with the healthcare provider about the specific details of the surgery.
Choice D reason:
An incident report is not necessary in this context as the situation is related to informed consent and not an error or safety issue.

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A nurse is caring for a client who is scheduled to have his alanine aminotransferase (ALT) level checked. The client asks the nurse to explain the laboratory test. Which of the following is an appropriate response by the nurse?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 2 days postoperative following bowel resection and reports sudden, severe abdominal pain. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse is caring for a client who is scheduled for surgery. While the nurse is witnessing the client's signature, the client states, "I trust my doctor, but I don't understand what is meant by resecting my intestines." Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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