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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. Asking the client to describe their pain allows the nurse to gather subjective information directly from the client, which can provide valuable insight into the quality, intensity, location, and duration of the pain.
A. This option focuses on pain management rather than pain assessment. While identifying effective pain relief measures is important, it does not directly address the need to assess the quality of the client's pain.
B. While numeric pain scales can be useful for quantifying pain intensity, they do not capture the quality or characteristics of the pain.
D. Observing body language and movement can provide valuable information about the client's pain experience, such as grimacing, guarding, or difficulty moving. However, this approach primarily assesses pain behaviors rather than the quality of the pain itself.
Correct Answer is B
Explanation
B. Postural drainage involves placing the client in various positions to help drain secretions from different lobes of the lungs. There are typically five standard positions: head-down, head-up, on the side with the affected lung uppermost, on the side with the affected lung lowermost, and lying prone.
A. Performing postural drainage immediately after meals is not recommended because it can increase the risk of vomiting or aspiration, especially in individuals with chronic obstructive pulmonary disease (COPD) who may already have compromised lung function.
C. In postural drainage, the client is typically instructed to breathe deeply and slowly to maximize the effectiveness of the technique.
D. While ABGs may be necessary for monitoring respiratory status in clients with COPD, they are not specifically required prior to performing postural drainage.
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