A nurse is collecting data from a patient who is African American and has cholecystitis.
Which of the following areas should the nurse inspect to monitor for the presence of jaundice?
The sclera
Nail beds
Periumbilical area
Webbed areas of the fingers .
The Correct Answer is A
Choice A rationale
Jaundice, a common symptom of cholecystitis, is a yellow discoloration of the skin and whites of the eyes (sclera) caused by an excess of bilirubin in the blood. The sclera is often the first place where jaundice is noticeable because the high amount of elastin in the sclera binds to bilirubin, causing a yellowish discoloration.
Choice B rationale
While nail beds can sometimes show signs of certain health issues, they are not typically used to monitor for the presence of jaundice. Jaundice primarily causes yellowing of the skin and the whites of the eyes.
Choice C rationale
The periumbilical area (around the belly button) is not typically used to monitor for the presence of jaundice. Jaundice primarily causes yellowing of the skin and the whites of the eyes.
Choice D rationale
The webbed areas of the fingers are not typically used to monitor for the presence of jaundice. Jaundice primarily causes yellowing of the skin and the whites of the eyes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The most common position for administering an enema is the left lateral position, where the patient lies on their left side with their right leg flexed toward their chest. This position allows for the best flow of the enema solution by gravity along the natural curves of the sigmoid colon and rectum.
Choice B rationale
Position B is not typically recommended for enema administration.
Choice C rationale
Position C is not typically recommended for enema administration.
Choice D rationale
Position D is not typically recommended for enema administration
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale
Observing mucous membranes for dryness can indicate dehydration.
Choice B rationale
Providing frequent oral care with moist swabs can help alleviate the discomfort of a dry mouth due to NPO status.
Choice C rationale
Offering the client small sips of water is not appropriate as the client is on a diet of nothing by mouth (NPO) except ice chips.
Choice D rationale
Increasing the rate of intravenous (IV) fluids can help prevent dehydration.
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