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
Dumping syndrome is a condition that occurs when food moves too fast from the stomach to the duodenum, usually after a surgery to the stomach. Early signs of dumping syndrome include abdominal cramps, diarrhea, nausea, vomiting, flushing, dizziness, and rapid heart rate. One of the late symptoms of dumping syndrome is sweating. Therefore, sweating and pallor can indicate the occurrence of dumping syndrome.
Choice B rationale
Bradycardia and indigestion are not typically associated with dumping syndrome. While digestive issues can occur, they usually manifest as nausea, vomiting, and diarrhea rather than indigestion.
Choice C rationale
Dry skin and stomach pain are not typically associated with dumping syndrome. The primary symptoms of dumping syndrome are related to the digestive system and the body’s response to rapid changes in blood sugar levels.
Choice D rationale
Double vision and chest pain are not typically associated with dumping syndrome. These symptoms may be indicative of other medical conditions and should be evaluated separately
Correct Answer is D
Explanation
Choice A rationale
Chlorhexidine is an antiseptic that is used for cleaning the skin or the hands and helps to prevent infections caused by bacteria. However, it is not the recommended cleansing agent for hand hygiene in a Clostridium difficile infection.
Choice B rationale
Alcohol-based antiseptics are commonly used for hand hygiene in healthcare settings. However, they are not effective against Clostridium difficile spores.
Choice C rationale
Povidone-iodine is an antiseptic used for skin disinfection before and after surgery. It may not be effective against Clostridium difficile spores.
Choice D rationale
Soap and water are recommended for hand hygiene when caring for a patient with a Clostridium difficile infection. This is because soap and water are effective in removing C. difficile spores from hands.
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