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: Keeping the room temperature cool may help with comfort but is not the immediate priority.

Choice B reason: Determining the client's food preferences is important for nutritional management but is not the first action to take.

Choice C reason:

The correct answer is c) because maintaining a patent intravenous site is crucial for administering fluids and medications to address severe dehydration and malnutrition.

Choice D reason: Teaching relaxation techniques can help with restlessness but is not the most immediate concern.

Correct Answer is ["200"]

Explanation

Calculation steps:

Step 1: Determine the total volume to be infused. 100 mL

Step 2: Determine the time for infusion. 30 minutes

Step 3: Convert time to hours. 30 minutes ÷ 60 minutes/hour Result: 0.5 hours

Step 4: Calculate the rate in mL/hour. 100 mL ÷ 0.5 hours Result: 200 mL/hour

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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

An adult woman with Grave's disease is admitted with severe dehydration and malnutrition. She is currently restless and refusing to eat. Which action is most important for the nurse to implement?

Correct Answer is C

Explanation

Correct Answer is ["200"]

Explanation

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