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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Pyridostigmine is a cholinergic medication that can affect bladder function, and difficulty with urination could indicate a bladder obstruction, which is a contraindication for this medication.
B. Trouble sleeping or insomnia is not typically associated with pyridostigmine use.
C. Unexplained weight loss is not a common side effect of pyridostigmine.
D. Administering pyridostigmine with food or shortly after a meal may help minimize gastrointestinal side effects such as nausea and abdominal discomfort. This however, is not of immediate concern when administering pyridostigmine.
Correct Answer is D
Explanation
D A stool softener can help prevent straining during bowel movements, which could increase intraocular pressure and potentially harm the surgical site. Additionally, the nurse should advise the client to avoid activities that could increase pressure in the eye, such as bending at the waist, lifting heavy objects, or engaging in strenuous activities for a certain period post-surgery.
A Monitoring for changes in pupillary sizes is not specific to this type of surgery.
B Turn, cough, and deep breathe every 2 hours: This instruction is more relevant for clients who have undergone surgery or are at risk of developing respiratory complications, such as pneumonia. It is not specifically related to cataract extraction with a lens implant.
C Clients are usually advised to sleep with the head elevated or to avoid lying on the operative side to minimize the risk of intraocular pressure changes and discomfort.
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