A nurse is collecting data from a client who has obstruction and inflammation of the common bile duct due to cholelithiasis. Which of the following findings is expected for this condition?

Ecchymosis of the extremities

Tenderness in the left upper abdomen

Straw-colored urine

Fatty stools

Answer and Explanation

The Correct Answer is D

A. Ecchymosis of the extremities: Ecchymosis refers to the medical term for a bruise. It's characterized by a discoloration of the skin resulting from bleeding underneath, typically caused by trauma to the blood vessels. This is not directly related to cholelithiasis.

B. Tenderness in the left upper abdomen: Tenderness in the left upper abdomen might be associated with conditions such as pancreatitis or splenic issues, not directly with obstruction and inflammation of the common bile duct due to cholelithiasis.

C. Straw-colored urine: Straw-colored urine is normal and healthy. Dark-colored or cloudy urine might indicate underlying issues, but straw-colored urine is generally a sign of proper hydration.

D. Fatty stools: When the common bile duct is obstructed due to cholelithiasis, proper digestion of fats doesn't occur, leading to the passage of fatty stools. This is due to the inability to properly digest and absorb fats, leading to their presence in the stool.

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Correct Answer is C

Explanation

A. Keep the head of the bed elevated at 15 degrees.

This is not sufficient for preventing aspiration and ensuring proper digestion. The head of the bed should be elevated at least 30 degrees to reduce the risk of aspiration and promote better digestion of enteral feedings.

B. Place enough formula in the feeding bag to last for 8 hr of continuous feeding: It is recommended to change the feeding formula and bag every 24 hours. Placing formula for an extended period can increase the risk of bacterial growth.

C. Flush the tube with 30 ml of water every 4 hr: Regular flushing of the tube helps maintain patency, prevents clogging, and ensures proper hydration. Flushing every 4 hours is a standard practice for continuous feeding.

D. Change the feeding bag and tubing every 72 hr: Feeding bags and tubing should be changed more frequently, typically every 24 hours, to reduce the risk of infection.

A. Check the client for a positive Chvostek's sign. B. Discontinue the TPN infusion. C. Request a potassium replacement. D. Administer glucagon IM.

Correct Answer is C

Explanation

A. Check the client for a positive Chvostek's sign.
Chvostek's sign is a clinical sign of hypocalcemia (low calcium levels), not related to the client's potassium levels. The given potassium level is low, not calcium.

B. Discontinue the TPN infusion.
While the potassium level is low, discontinuing TPN without addressing the potassium deficiency can lead to further complications. TPN can be adjusted to include potassium supplementation.

C. Request a potassium replacement.
The client's low potassium level (3.0 mEq/L) requires potassium replacement. This can be done through the TPN solution or via a separate IV infusion. This choice is correct.

D. Administer glucagon IM.
Glucagon is not used to treat low potassium levels.

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A nurse is collecting data from a client who has obstruction and inflammation of the common bile duct due to cholelithiasis. Which of the following findings is expected for this condition?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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