A patient with cholelithiasis has a gallstone lodged in the common bile duct and is unable to eat or drink without becoming nauseated and vomiting.
Which finding should the nurse report to the healthcare provider?
Amber urine.
Belching.
Flatulence.
Yellow sclera.
The Correct Answer is D
Choice A rationale:
Amber urine can be a sign of dehydration, but it is not specific to cholelithiasis with a gallstone lodged in the common bile duct.
While it's important to monitor hydration status in patients with nausea and vomiting, amber urine alone would not be the most urgent finding to report to the healthcare provider in this context.
Choice B rationale:
Belching is a common symptom of gastrointestinal disorders, but it is not specific to cholelithiasis with a gallstone obstruction. It can be caused by various factors, such as swallowing air, eating too quickly, or drinking carbonated beverages.
While belching might be a symptom the nurse documents, it would not be the most concerning finding to report immediately.
Choice C rationale:
Flatulence is another common gastrointestinal symptom that can have various causes, including dietary choices, bacterial fermentation in the intestines, and certain medications.
It is not specific to cholelithiasis with a gallstone obstruction and would not be the most relevant finding to prioritize reporting.
Choice D rationale:
Yellow sclera, also known as jaundice, is a significant finding that strongly suggests cholestasis, which is the obstruction of bile flow.
Bile, a fluid produced by the liver, aids in digestion and gives stool its brownish color.
When bile flow is obstructed, as in the case of a gallstone lodged in the common bile duct, bilirubin (a component of bile) builds up in the bloodstream and tissues, leading to yellowing of the skin and sclera (the whites of the eyes).
This is a crucial finding to report to the healthcare provider because it indicates a worsening of the patient's condition and the need for prompt intervention to address the obstruction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E","F","G"]
Explanation
The correct answer is choiceb. Identify the client using 2 client identifiers,c. Perform hand hygiene,e. Don gloves,f. Check the skin around the face, andg. Assess respiratory function.
Choice A rationale:
Determining if the client needs to go to the bathroom is not directly related to the immediate preparation for oxygen administration. However, it can be considered as part of overall patient comfort and care.
Choice B rationale:
Identifying the client using 2 client identifiers is crucial to ensure the correct patient is receiving the correct treatment, which is a standard safety protocol in healthcare settings.
Choice C rationale:
Performing hand hygiene is essential to prevent the spread of infection and maintain a sterile environment.
Choice D rationale:
Brushing the client’s teeth is not a necessary step before applying a simple face mask for oxygen administration. It is more related to general oral hygiene.
Choice E rationale:
Donning gloves is important to protect both the nurse and the patient from potential contamination and infection.
Choice F rationale:
Checking the skin around the face is important to ensure there are no existing sores or irritations that could be exacerbated by the mask.
Choice G rationale:
Assessing respiratory function is critical to determine the patient’s baseline respiratory status and to monitor the effectiveness of the oxygen therapy.
Correct Answer is B
Explanation
Choice A rationale:
Colloidal oatmeal-based lotions can be soothing and moisturizing for dry, itchy skin, but they are not effective in treating the inflammation and scaling associated with psoriasis.
They do not address the underlying hyperproliferation of skin cells that is characteristic of psoriasis.
While they may provide temporary relief of symptoms, they are not a long-term solution for managing the condition.
Choice B rationale:
Topical corticosteroids are the mainstay of treatment for psoriasis.
They work by reducing inflammation, slowing the growth of skin cells, and easing itching and scaling. They come in a variety of strengths and formulations, including creams, ointments, gels, and foams.
The type of corticosteroid and the strength of the medication will depend on the severity of the psoriasis and the location of the lesions.
It's important to follow the healthcare provider's instructions for use carefully, as overuse of topical corticosteroids can lead to side effects such as thinning of the skin and rebound flares.
Choice C rationale:
Topical analgesics, such as lidocaine or benzocaine, can be used to temporarily relieve pain and itching associated with psoriasis.
However, they do not address the underlying inflammation and scaling, and they should not be used as a primary treatment for the condition.
They may be used as adjunctive therapy in conjunction with topical corticosteroids or other psoriasis medications.
Choice D rationale:
Topical antifungal medications are used to treat fungal infections of the skin, such as athlete's foot or ringworm. They are not effective in treating psoriasis, which is an autoimmune condition rather than a fungal infection.
Using a topical antifungal medication for psoriasis could potentially worsen the condition or lead to other skin problems.
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