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 ["38"]

Explanation

Drop rate (gtt/min) = Volume to be infused (mL)/ Time of infusion (minutes) × Drop factor (gtt/mL)

Given:

Volume to be infused (V) = 75 mL Time of infusion (T) = 30 minutes Drop factor = 15 gtt/mL
Using the formula:

Drop rate (gtt/min)= [75/30]*15 Drop rate (gtt/min)=2.5×15

Drop rate (gtt/min)=37.5
Rounding to the nearest whole number, the nurse should regulate the IV to deliver approximately 38 gtt/minute.

A. Imbalanced nutrition: less than body requirements. B. Risk for aspiration related to difficulty swallowing. C. Chronic pain related to tissue destruction by tumor. D. Anxiety and grieving related to progression of disease.

Correct Answer is B

Explanation

B. Aspiration can lead to serious respiratory complications such as pneumonia. Since the client reports difficulty swallowing (dysphagia) and has a high pain level, addressing the risk for aspiration is crucial to prevent further complications.

A. While nutrition is essential for overall health, it may not be the priority in this case given the severity of other symptoms such as pain, dysphagia, and anxiety.

C. Esophageal cancer can cause significant pain due to tissue destruction by the tumor, which can affect the client's quality of life and ability to function. This however, should be addressed after immediate concerns in the ABCs.

D. While addressing the client's emotional needs is important for holistic care, it may not be the immediate priority compared to managing symptoms such as pain and dysphagia,

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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

The healthcare provider prescribes an IV solution of clindamycin 850 mg in 75 mL of DW to infuse over 30 minutes. The drop factor is 15 gtt/mL. The nurse should regulate the IV to deliver how many glt/minute? (Enler numeric value only. If rounding is required, round to the nearest whole number.)

Correct Answer is ["38"]

Explanation

The nurse is caring for a client who has been admitted with a diagnosis of esophageal cancer. The client reports a pain level of 8 on a 0 to 10 pain scale, dysphagia, anorexia, anxiety and a hoarse voice. Which nursing problem is the priority for this client?

Correct Answer is B

Explanation

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