A nurse is collecting data from a client who has obstruction and inflammation of the common bile duct due to cholelithiasis. Which of the following findings is expected for this condition?
Ecchymosis of the extremities
Tenderness in the left upper abdomen
Straw-colored urine
Fatty stools
The Correct Answer is D
A. Ecchymosis of the extremities: Ecchymosis refers to the medical term for a bruise. It's characterized by a discoloration of the skin resulting from bleeding underneath, typically caused by trauma to the blood vessels. This is not directly related to cholelithiasis.
B. Tenderness in the left upper abdomen: Tenderness in the left upper abdomen might be associated with conditions such as pancreatitis or splenic issues, not directly with obstruction and inflammation of the common bile duct due to cholelithiasis.
C. Straw-colored urine: Straw-colored urine is normal and healthy. Dark-colored or cloudy urine might indicate underlying issues, but straw-colored urine is generally a sign of proper hydration.
D. Fatty stools: When the common bile duct is obstructed due to cholelithiasis, proper digestion of fats doesn't occur, leading to the passage of fatty stools. This is due to the inability to properly digest and absorb fats, leading to their presence in the stool.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Monitor the client for manifestations of fluid overload: This action is not specifically related to C. difficile infection. Monitoring for fluid overload might be necessary in other situations, but it is not the appropriate action for this scenario.
B. Use alcohol hand sanitizer following client care: While alcohol-based hand sanitizers are effective against many pathogens, they are not effective against C. difficile spores. Washing hands with soap and water is necessary to remove the spores.
C. Disinfect equipment with bleach solution. This is the correct answer. Clostridium difficile (C. difficile) spores are resistant to many disinfectants, but they are killed by bleach. Therefore, equipment and surfaces should be cleaned with a bleach solution to prevent the spread of the infection.
D. Implement neutropenia isolation: Neutropenia isolation is a precautionary measure taken when a person has a low count of neutrophils, a type of white blood cell. This option is not directly related to C. difficile infection.
Correct Answer is C
Explanation
A. Keep the head of the bed elevated at 15 degrees.
This is not sufficient for preventing aspiration and ensuring proper digestion. The head of the bed should be elevated at least 30 degrees to reduce the risk of aspiration and promote better digestion of enteral feedings.
B. Place enough formula in the feeding bag to last for 8 hr of continuous feeding: It is recommended to change the feeding formula and bag every 24 hours. Placing formula for an extended period can increase the risk of bacterial growth.
C. Flush the tube with 30 ml of water every 4 hr: Regular flushing of the tube helps maintain patency, prevents clogging, and ensures proper hydration. Flushing every 4 hours is a standard practice for continuous feeding.
D. Change the feeding bag and tubing every 72 hr: Feeding bags and tubing should be changed more frequently, typically every 24 hours, to reduce the risk of infection.
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