A nurse is caring for a client who has cholecystitis with cholelithiasis and obstruction of the common bile duct. The nurse should expect the client's urine to appear which of the following colors?
Pale yellow
Red
Greenish-brown
Dark and concentrated
The Correct Answer is C
Choice A reason: Pale yellow is the normal color of urine, indicating adequate hydration and no bilirubin in the urine. Bilirubin is a pigment that is produced when red blood cells are broken down. It is normally excreted in the bile, but if the bile duct is obstructed, it can accumulate in the blood and urine, causing jaundice and dark urine.
Choice B reason: Red urine can indicate blood in the urine, which can be caused by various conditions such as urinary tract infection, kidney stones, trauma, or cancer. It is not related to bile duct obstruction or cholecystitis.
Choice C reason: Greenish-brown urine can indicate bilirubin in the urine, which can be caused by bile duct obstruction or liver disease. It is a sign of cholestasis, which is a reduced or stopped flow of bile. The nurse should monitor the client for other signs of cholestasis such as jaundice, clay-colored stools, pruritus, and abdominal pain.
Choice D reason: Dark and concentrated urine can indicate dehydration, which can be caused by various factors such as fluid loss, fever, vomiting, or diarrhea. It is not related to bile duct obstruction or cholecystitis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Pyuria, or pus in the urine, is not a direct sign of fluid volume overload. It may indicate a urinary tract infection, kidney stones, or other renal problems.
Choice B reason: Weight loss is not a typical finding of fluid volume overload. In fact, weight gain is a common symptom of fluid retention, as the body holds more fluid than it excretes.
Choice C reason: Jugular vein distention, or the bulging of the neck veins, is a serious indicator of fluid volume overload. It reflects increased pressure in the right side of the heart and the systemic circulation. It may also signal heart failure, pulmonary hypertension, or pericardial tamponade.
Choice D reason: Muscle contractions are not directly related to fluid volume overload. They may be caused by electrolyte imbalances, dehydration, muscle fatigue, or nerve disorders.
Correct Answer is D
Explanation
Choice A reason: Drinking a minimum of 12 ounces of fluid with each meal is not recommended for a client who has dumping syndrome. Fluids can increase the gastric volume and accelerate the gastric emptying, leading to more severe symptoms. The nurse should advise the client to drink fluids between meals, not with meals.
Choice B reason: Choosing foods that are high in simple carbohydrates is not recommended for a client who has dumping syndrome. Simple carbohydrates can cause a rapid rise and fall of blood glucose levels, resulting in hypoglycemia and weakness. The nurse should advise the client to choose foods that are high in protein and fat, and low in sugar.
Choice C reason: Staying upright when eating and for 30 minutes afterward is not recommended for a client who has dumping syndrome. This position can facilitate the gastric emptying and worsen the symptoms. The nurse should advise the client to lie down after eating to slow down the gastric emptying.
Choice D reason: Eating several small meals daily spaced at equal intervals is recommended for a client who has dumping syndrome. This can help reduce the gastric volume and pressure, and prevent the rapid delivery of food into the small intestine. The nurse should advise the client to eat four to six small meals per day, and avoid skipping meals.
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