A client 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.
Yellow sclera.
Flatulence.
Belching.
The Correct Answer is B
B. Obstruction of bile flow leads to accumulation of bilirubin, a pigment produced by the breakdown of red blood cells, in the bloodstream and causes jaundice (yellowing of the sclera). Yellow sclera is a concerning sign that should be reported promptly to the healthcare provider as it indicates potential bile duct obstruction and impaired liver function
A. Amber urine refers to urine that is dark yellow, often indicating concentrated urine due to dehydration or certain medications. While amber urine may be noted in various conditions, it is not specifically indicative of a complication related to cholelithiasis.
C. While flatulence may be uncomfortable for the client, it is not typically indicative of a complication such as a gallstone lodged in the common bile duct.
D. belching may be uncomfortable for the client but is not typically indicative of a complication such as a gallstone lodged in the common bile duct.
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Related Questions
Correct Answer is B
Explanation
B. Postural drainage involves placing the client in various positions to help drain secretions from different lobes of the lungs. There are typically five standard positions: head-down, head-up, on the side with the affected lung uppermost, on the side with the affected lung lowermost, and lying prone.
A. Performing postural drainage immediately after meals is not recommended because it can increase the risk of vomiting or aspiration, especially in individuals with chronic obstructive pulmonary disease (COPD) who may already have compromised lung function.
C. In postural drainage, the client is typically instructed to breathe deeply and slowly to maximize the effectiveness of the technique.
D. While ABGs may be necessary for monitoring respiratory status in clients with COPD, they are not specifically required prior to performing postural drainage.
Correct Answer is D
Explanation
D. The correct instruction to include in a discharge teaching plan for an adult client with hypernatremia is to review food labels for sodium content. Hypernatremia is a condition characterized by high levels of sodium in the blood, and it is often due to fluid loss rather than excessive sodium intake.
A. Hypernatremia is characterized by elevated levels of sodium in the blood, and reducing sodium intake is typically part of the treatment plan. Instructing the client to use salt tablets would exacerbate the hypernatremia and could lead to further complications.
B. This instruction is not directly related to managing hypernatremia. While monitoring urine output is important for assessing hydration status and kidney function, it may not specifically address the underlying cause of hypernatremia.
C. Hypernatremia is often caused by dehydration or inadequate water intake, leading to elevated sodium levels in the blood. Therefore, hydrating is an important instruction but not the most important.
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