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The nurse is assessing a client with suspected acute cholecystitis. Which of the following findings would support a diagnosis of acute cholecystitis?
- A. Decreased serum bilirubin
- B. Increased high density lipoprotein cholesterol (HDL-C)
- C. Decreased serum aminotransferases
- D. Increased white blood cell count (WBC)
Correct Answer: D
Rationale: An increased WBC count (D) indicates inflammation or infection, supporting a diagnosis of acute cholecystitis. Bilirubin (A) and aminotransferases (C) may rise, and HDL-C (B) is unrelated.
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The nurse is caring for a client who is postprocedure following an endoscopy. Which priority action should the nurse take prior to resuming the client's diet?
- A. Assess the client's oxygenation level
- B. Assess for the return of the client's gag reflex
- C. Have the healthcare provider speak with the client regarding results of the procedure
- D. Start with a soft diet to see if the client will tolerate
Correct Answer: B
Rationale: Assessing the gag reflex (B) ensures safe swallowing post-endoscopy to prevent aspiration before resuming the diet.
The nurse is caring for a postoperative client who underwent abdominal surgery and is receiving patient-controlled analgesia (PCA) with morphine for pain management. The nurse notes that the client is sedated but still complaining of severe pain. What is the most appropriate action for the nurse to take?
- A. Increase the PCA dosage
- B. Administer a non-opioid analgesic
- C. Discontinue PCA and Administer Intramuscular (IM) Morphine
- D. Notify the healthcare provider
Correct Answer: D
Rationale: Notifying the provider (D) is appropriate when the client is sedated yet in severe pain, indicating potential PCA inadequacy or complications requiring reassessment.
The nurse is caring for a client receiving total parenteral nutrition (TPN) through a central line. The nurse plans on taking which appropriate action?
- A. Inserting an indwelling urinary catheter.
- B. Weighing the client in the morning before the first void.
- C. Placing a mask on the client before changing the central line dressing.
- D. Establishing continuous cardiac monitoring.
Correct Answer: B
Rationale: Weighing the client daily (B) monitors fluid balance and nutritional status, critical for TPN management. Catheters (A), masks (C), and cardiac monitoring (D) are not routinely required unless indicated.
The emergency department (ED) nurse is caring for a 45-year-old male client.
Item 4 of 6
Orders
0600
• Cardiac monitoring
• NPO
• CBC
• CMP
• LFTs
• Amylase
• Lipase
• CT abdomen with contrast
Nurses’ Notes
0600: The client reports sudden, severe epigastric pain. He has a history of chronic alcohol use disorder (30+ years), GERD, and hypertension. His home medications include pantoprazole and lisinopril. Upon assessment, the client is noted to be alert and oriented x4. He is mildly diaphoretic, with pulses 2+ and regular. Abdomen is distended, guarding on palpation, diminished bowel sounds, and no stool in the last 24 hours. He reports nausea and vomiting, and his pain is worse after eating fatty foods, rated 7/10 and radiating to his back. Breath sounds slightly diminished bilaterally, no adventitious sounds, denies cough or dyspnea. He reports heavy alcohol intake two days ago. Fingerstick glucose is 145 mg/dL (8.06 mmol/L) [70-110 mg/dL; 4-6 mmol/L]. Temperature is 101.3°F (38.5°C), heart rate of 112 bpm, respiratory rate of 24 breaths/min, blood pressure of 98/64 mmHg, and oxygen saturation of 95% on room air.
0630: Physician confirmed the diagnosis of acute pancreatitis based on clinical presentation, laboratory findings, and imaging studies.
Laboratory & Imaging Results
0630
Exam: CT Abdomen and Pelvis with IV Contrast
Indication: Acute onset of epigastric abdominal pain, nausea, vomiting.
Findings:
Pancreas: Diffuse enlargement of the pancreas with heterogeneous enhancement. Peripancreatic fat stranding and inflammatory changes are present, most pronounced around the pancreatic head and body. No evidence of necrosis at this time. No discrete mass or cystic lesion noted. Biliary system: Gallbladder is distended with no wall thickening or pericholecystic fluid. No gallstones visualized. Common bile duct is normal in caliber (~5 mm). Liver, spleen, kidneys, and adrenal glands: Normal in appearance. No focal lesions. Bowel: No obstruction or bowel wall thickening noted.
Impression:
Imaging findings are consistent with acute interstitial edematous pancreatitis.
No evidence of pancreatic necrosis or pseudocyst formation at this time.
The nurse anticipates an order to administer intravenous ..................in order to............
- A. Plasma colloid expander
- B. Hypertonic saline
- C. Isotonic crystalloid
- D. Reduce pulmonary edema
- E. Decrease electrolyte toxicity
- F. Replace fluid loss from third spacing
Correct Answer: C,F
Rationale: Isotonic crystalloid (C), such as Lactated Ringer's, is used to replace fluid loss from third spacing (F) in acute pancreatitis, addressing hypovolemia due to inflammation and fluid shifts.
A client with peptic ulcer disease from chronic nonsteroidal anti-inflammatory drug (NSAID) use is prescribed misoprostol. The nurse would be correct in informing the client that this medication does which of the following?
- A. Decreases gas formation
- B. Increases the speed of gastric emptying
- C. Lines the stomach for protection
- D. Increases the lower esophageal sphincter pressure
Correct Answer: C
Rationale: Misoprostol (C) protects the stomach by increasing mucus production and reducing acid secretion, helping to heal NSAID-induced ulcers.