A client with cholelithiasis has a gallstone lodged in the common bile duct and is unable to eat or drink without becoming nauseated and vomiting. Which finding should the nurse report to the healthcare provider?

Amber urine.

Yellow sclera.

Flatulence.

Belching.

Answer and Explanation

The Correct Answer is B

B. Obstruction of bile flow leads to accumulation of bilirubin, a pigment produced by the breakdown of red blood cells, in the bloodstream and causes jaundice (yellowing of the sclera). Yellow sclera is a concerning sign that should be reported promptly to the healthcare provider as it indicates potential bile duct obstruction and impaired liver function

A. Amber urine refers to urine that is dark yellow, often indicating concentrated urine due to dehydration or certain medications. While amber urine may be noted in various conditions, it is not specifically indicative of a complication related to cholelithiasis.

C. While flatulence may be uncomfortable for the client, it is not typically indicative of a complication such as a gallstone lodged in the common bile duct.

D. belching may be uncomfortable for the client but is not typically indicative of a complication such as a gallstone lodged in the common bile duct.

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Correct Answer is D

Explanation

D. The priority nursing intervention should be to assess and stabilize the patient's immediate medical needs. The confusion and vomiting could be indicative of increased intracranial pressure or another acute condition requiring immediate attention. Therefore, the most appropriate first action would be to complete a head-to-toe neurological assessment.

A. Determining the last dose of corticosteroids may not address the immediate concerns of confusion and projectile vomiting.

B. Administering an antiemetic is not the priority action as the vomiting is likely due to head trauma with subsequent raised ICP.

C. Understanding the baseline neurological status is essential for subsequent assessment and management but it may not address the immediate concerns of confusion and vomiting.

A. Insert a nasogastric tube (NGT) and attach to low intermittent suction. B. Place an indwelling urinary catheter and attach a bedside drainage unit. C. Send the client to x-ray for a flat plate of the abdomen. D. Give a prescribed analgesic for temperature above 101°F (38.3°C).

Correct Answer is A

Explanation

A. Inserting a nasogastric tube (NGT) and attaching it to low intermittent suction would be appropriate in this situation. Dark brown emesis could indicate gastrointestinal bleeding, which may require gastric decompression to prevent further vomiting and assess the volume and characteristics of the gastric contents.

B. Placing an indwelling urinary catheter and attaching a bedside drainage unit is not the priority intervention in this scenario.

C. Sending the client to x-ray for a flat plate of the abdomen may provide diagnostic information, but it is not the most immediate intervention needed in this situation.

D. Giving a prescribed analgesic for a temperature above 101°F (38.3°C) is not the priority intervention in this scenario.

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A client with cholelithiasis has a gallstone lodged in the common bile duct and is unable to eat or drink without becoming nauseated and vomiting. Which finding should the nurse report to the healthcare provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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