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?
Faty stools
Ecchymosis of the extremities
Straw-colored urine
Tenderness in the left upper abdomen
The Correct Answer is A
Choice A: Faty stools. This is a finding that is expected for a client who has obstruction and inflammation of the common bile duct due to cholelithiasis, which is the presence of gallstones in the gallbladder or bile ducts. The common bile duct carries bile from the liver and gallbladder to the duodenum, where it helps digest fats. If the common bile duct is obstructed by a gallstone, bile cannot reach the duodenum and fats cannot be properly absorbed. This results in fatty stools, which are also known as steatorrhea. Fatty stools are pale, bulky, greasy, and foul-smelling.
Choice B: Ecchymosis of the extremities. This is not a finding that is expected for a client who has obstruction and inflammation of the common bile duct due to cholelithiasis. Ecchymosis of the extremities is a sign of bleeding under the skin, which can be caused by trauma, coagulation disorders, or medications. It is not related to bile duct obstruction or gallstones.
Choice C: Straw-colored urine. This is not a finding that is expected for a client who has obstruction and inflammation of the common bile duct due to cholelithiasis. Straw-coloured urine is a normal colour of urine, which indicates adequate hydration and kidney function. It is not affected by bile duct obstruction or gallstones.
Choice D: Tenderness in the left upper abdomen. This is not a finding that is expected for a client who has obstruction and inflammation of the common bile duct due to cholelithiasis. Tenderness in the left upper abdomen is a sign of splenomegaly, which is an enlargement of the spleen due to infection, inflammation, or cancer. It is not related to bile duct obstruction or gallstones.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: Docusate. This is not a treatment that the nurse should expect to administer to a client with an acute exacerbation of ulcerative colitis. Docusate is a stool softener that can prevent constipation and straining, but it is not indicated for ulcerative colitis.
Choice B: A corticosteroid medication. This is a treatment that the nurse should expect to administer to a client with an acute exacerbation of ulcerative colitis, which is a chronic inflammatory bowel disease that causes ulcers and inflammation in the colon and rectum. A corticosteroid medication, such as prednisone, can reduce inflammation, suppress the immune system, and relieve symptoms such as diarrhea, bleeding, and pain.
Choice C: Aspirin. This is not a treatment that the nurse should expect to administer to a client with an acute exacerbation of ulcerative colitis. Aspirin is a nonsteroidal anti-inflammatory drug (NSAID) that can relieve pain and inflammation, but it can also irritate the gastrointestinal mucosa and worsen ulcerative colitis.
Choice D: A bowel cathartic medication. This is not a treatment that the nurse should expect to administer to a client with an acute exacerbation of ulcerative colitis. A bowel cathartic medication, such as bisacodyl, can stimulate bowel movements and cleanse the colon, but it can also cause dehydration, electrolyte imbalance, and aggravate ulcerative colitis.
Correct Answer is D
Explanation
Choice A: Implement neutropenia isolation. This is not an action that the nurse should take for a client who has developed a Clostridium difficile infection. Neutropenia isolation is a type of protective isolation that is used for
clients who have low white blood cell counts and are at risk of infection from others. It is not indicated for clients who have Clostridium difficile infection, which is not transmited through the air.
Choice B: Use alcohol hand sanitizer following client care. This is not an action that the nurse should take for a client who has developed a Clostridium difficile infection. Alcohol hand sanitizer is ineffective against Clostridium difficile spores and can increase the risk of transmission. The nurse should wash their hands with soap and water, which can remove the spores from the skin.
Choice C: Monitor the client for manifestations of fluid overload. This is not an action that the nurse should take for a client who has developed a Clostridium difficile infection. Fluid overload is a condition that occurs when the body retains excess fluid and causes symptoms such as edema, dyspnea, and hypertension. It is not related to Clostridium difficile infection, which can cause fluid loss due to diarrhea and dehydration. The nurse should monitor the client for manifestations of fluid deficit, such as dry mucous membranes, tachycardia, and hypotension.
Choice D: Disinfect equipment with bleach solution. This is an action that the nurse should take for a client who has developed a Clostridium difficile infection, which is a bacterial infection that causes severe diarrhea and inflammation of the colon. Clostridium difficile spores are resistant to most disinfectants and can survive on surfaces for a long time. The nurse should disinfect equipment with bleach solution, which can kill the spores and prevent transmission.
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