A client with cholelithiasis is admitted with jaundice due to obstruction of the common bile duct. Which finding is most important for the nurse to report to the healthcare provider?

Bile-stained emesis.

Clay-colored stool.

Distended, hard, and rigid abdomen.

Radiating, sharp pain in the right shoulder.

Answer and Explanation

The Correct Answer is C

Choice A reason: Bile-stained emesis indicates an obstruction, but it is not as immediately critical as a distended, hard, and rigid abdomen.

Choice B reason: Clay-colored stool is a sign of bile duct obstruction but is not as urgent as the abdomen findings.

Choice C reason:

The correct answer is c) because a distended, hard, and rigid abdomen suggests peritonitis or a perforated organ, which requires immediate medical intervention.

Choice D reason: Radiating, sharp pain in the right shoulder is common in gallbladder issues but is not as immediately life-threatening as a distended, hard, and rigid abdomen.

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Correct Answer is A

Explanation

Choice A reason:

The correct answer is a) because visualizing the abdominal incision will help the nurse assess for wound dehiscence or evisceration, which requires immediate intervention.

Choice B reason: Notifying the healthcare provider is necessary but comes after assessing the wound.

Choice C reason: Obtaining sterile towels soaked in saline is important if dehiscence or evisceration is confirmed but is not the first action.

Choice D reason: Reassuring the client is important but does not address the immediate need to assess the wound.

A. Deep partial-thickness. B. Full-thickness. C. Superficial partial-thickness. D. Deep full-thickness.

Correct Answer is B

Explanation

Choice A reason: Deep partial-thickness burns are characterized by blisters and significant pain.

Choice B reason:

The correct answer is b) because full-thickness burns involve all layers of the skin and can extend into underlying tissues. They often appear brown or yellow and are usually painless due to nerve damage.

Choice C reason: Superficial partial-thickness burns affect the epidermis and part of the dermis, causing pain and redness.

Choice D reason: Deep full-thickness burns are also a possible answer, but full-thickness better describes the extent and characteristics given.

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A client with cholelithiasis is admitted with jaundice due to obstruction of the common bile duct. Which finding is most important for the nurse to report to the healthcare provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A male client who had abdominal surgery 5 days ago and was hospitalized because of a wound infection tells the nurse that he feels like his insides just spilled out when he coughed. Which action should the nurse take first?

Correct Answer is A

Explanation

The nurse is caring for a client with a burn that is severely edematous with a wound bed that is brown and yellow in appearance. The client expresses feeling no pain. Which classification of burn depth should the nurse document?

Correct Answer is B

Explanation

The nurse is developing a plan of care for a client who reports blurred vision and who is newly diagnosed with type 2 diabetes mellitus (DM). Which outcome should the nurse include in the plan of care for this client?

Which client has the highest risk for developing skin cancer?

Following a transurethral resection of the prostate (TURP), a client is discharged from the hospital with an indwelling urinary catheter. Which instruction is most important for the nurse to include in the discharge teaching plan?

Which findings during the admission assessment should the nurse document that are related to a client diagnosed with Cushing's syndrome?

The nurse is teaching a client with cancer about skin care for the portal site receiving external beam radiation. Which client action about skin care indicates a need for further teaching?

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Which group of foods is best for the nurse to recommend for clients with a strong family history of colon and rectal cancers?