A client with cholelithiasis is admitted with jaundice due to obstruction of the common bile duct. Which finding is most important for the nurse to report to the healthcare provider?

Bile-stained emesis.

Clay-colored stool.

Distended, hard, and rigid abdomen.

Radiating, sharp pain in the right shoulder.

Answer and Explanation

The Correct Answer is C

Choice A reason: Bile-stained emesis indicates an obstruction, but it is not as immediately critical as a distended, hard, and rigid abdomen.

Choice B reason: Clay-colored stool is a sign of bile duct obstruction but is not as urgent as the abdomen findings.

Choice C reason:

The correct answer is c) because a distended, hard, and rigid abdomen suggests peritonitis or a perforated organ, which requires immediate medical intervention.

Choice D reason: Radiating, sharp pain in the right shoulder is common in gallbladder issues but is not as immediately life-threatening as a distended, hard, and rigid abdomen.

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Correct Answer is C

Explanation

Choice A reason: Platelet count is important for clotting but does not directly address the cause of fatigue in pernicious anemia.

Choice B reason: Liver enzymes are important for liver function but are not related to pernicious anemia.

Choice C reason:

The correct answer is c) because a complete blood count (CBC) provides information about hemoglobin and hematocrit levels, which are directly impacted by pernicious anemia and can explain the fatigue.

Choice D reason: Serum electrolytes are important but do not directly address the cause of fatigue in pernicious anemia.

A. Visualize the abdominal incision. B. Notify the healthcare provider. C. Obtain sterile towels soaked in saline. D. Assure the client that such feelings occur with wound infections.

Correct Answer is A

Explanation

Choice A reason:

The correct answer is a) because visualizing the abdominal incision will help the nurse assess for wound dehiscence or evisceration, which requires immediate intervention.

Choice B reason: Notifying the healthcare provider is necessary but comes after assessing the wound.

Choice C reason: Obtaining sterile towels soaked in saline is important if dehiscence or evisceration is confirmed but is not the first action.

Choice D reason: Reassuring the client is important but does not address the immediate need to assess the wound.

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A client with cholelithiasis is admitted with jaundice due to obstruction of the common bile duct. Which finding is most important for the nurse to report to the healthcare provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with pernicious anemia takes supplemental folate and self-administers monthly vitamin B12 injections. The client reports feeling increasingly fatigued. Which laboratory value should the nurse review?

Correct Answer is C

Explanation

A male client who had abdominal surgery 5 days ago and was hospitalized because of a wound infection tells the nurse that he feels like his insides just spilled out when he coughed. Which action should the nurse take first?

Correct Answer is A

Explanation

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