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 D
Explanation
A. Use salt tablets after strenuous exercise is incorrect. Clients with hypernatremia should avoid excessive sodium intake, including salt tablets, as this can worsen the condition.
B. Drink plenty of water whenever thirsty is incorrect. Thirst is a late sign of dehydration, and clients with hypernatremia should be encouraged to drink water regularly, even before feeling thirsty, to maintain proper hydration and correct sodium imbalances.
C. Monitor daily urine output volume is incorrect. While monitoring fluid balance is important, urine output alone does not directly address sodium intake or management, making reviewing food labels for sodium content a more critical intervention.
D. Review food labels for sodium content is correct. Clients with hypernatremia should limit sodium intake by carefully reading food labels and avoiding processed, canned, and fast foods that are high in sodium.
Correct Answer is A
Explanation
A. The priority nursing problem is the risk for aspiration related to difficulty swallowing (dysphagia). This condition poses an immediate risk to the client's safety as they may inhale food or liquids into the lungs, leading to aspiration pneumonia, which can be life-threatening.
B. While chronic pain is significant, addressing the risk of aspiration is more urgent in this context, especially considering the client's current symptoms.
C. Imbalanced nutrition is a concern, but it is secondary to the immediate risk posed by dysphagia and aspiration.
D. Although anxiety and grieving are important to address, they do not present an immediate threat to the client’s safety compared to the risk of aspiration.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.