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 C
Explanation
Choice A rationale
While a sore throat can be a side effect of an upper endoscopy, it is not the priority for monitoring after the procedure.
Choice B rationale
Abdominal bloating can occur after an upper endoscopy, but it is not the priority for monitoring.
Choice C rationale
Monitoring the return of the gag reflex is a priority after an upper endoscopy. The gag reflex may be impaired due to the use of local anesthetics during the procedure. An impaired gag reflex increases the risk of aspiration.
Choice D rationale
Belching can occur after an upper endoscopy, but it is not the priority for monitoring
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
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