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

Answer and Explanation

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.

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Correct Answer is ["A","D","E"]

Explanation

A. Perform leg exercises every 2 hr: Performing leg exercises every 2 hours is essential for preventing blood clots and maintaining circulation in immobile patients. This is especially important after surgery to prevent complications like deep vein thrombosis.

B. Irrigate the nasogastric tube every 4 to 8 hr: Irrigating the nasogastric tube is not a standard nursing practice and should not be done without a physician's order. The nasogastric tube is typically used for decompression, drainage, or feeding. If the tube becomes clogged or there are concerns about drainage, the nurse should contact the healthcare provider for further instructions.

C. Maintain bed rest for 48 hr following surgery: While some bed rest might be necessary immediately after surgery, the goal is to encourage mobility as soon as possible to prevent complications such as atelectasis and deep vein thrombosis. Patients are usually encouraged to mobilize as soon as they are medically stable, often within hours after surgery.

D. Encourage hourly use of an incentive spirometer while awake: Using an incentive spirometer helps prevent atelectasis and promotes lung expansion after surgery. Encouraging the patient to use the incentive spirometer hourly while awake is a common nursing intervention to maintain respiratory function postoperatively.

E. Document the color, consistency, and amount of nasogastric drainage: Documenting the color, consistency, and amount of nasogastric drainage is crucial for monitoring the patient's condition. Changes in these factors could indicate bleeding, infection, or other complications, and timely documentation helps healthcare providers assess the patient's status and make appropriate interventions.

A. Upper left quadrant B. Upper right quadrant C. Lower left quadrant D. Lower right quadrant

Correct Answer is C

Explanation

A. Upper left quadrant: Pain in the upper left quadrant of the abdomen can be associated with issues related to the spleen, stomach, or parts of the colon. It's not a typical location for pain related to diverticular disease.

B. Upper right quadrant: Pain in the upper right quadrant is often associated with issues related to the liver, gallbladder, or part of the colon. Again, not a typical location for diverticular disease-related pain.

C. Lower left quadrant: This is the correct answer. Diverticular disease often causes pain in the lower left quadrant of the abdomen, particularly if the inflammation or infection is in the sigmoid colon, which is a common site for diverticula.

D. Lower right quadrant: Pain in the lower right quadrant can be related to issues with the appendix or parts of the colon. It's not a typical location for diverticular disease-related pain.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the plan of care for a client who had surgery for a bowel obstruction. The client has a nasogastric tube in place. Which of the following actions should the nurse include in the client's plan of care? (Select all that apply.)

Correct Answer is ["A","D","E"]

Explanation

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Correct Answer is C

Explanation

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