A nurse is collecting data from a client who is African American has cholecystitis. Which of the following areas should the nurse inspect to monitor for the presence of jaundice?
Webbed areas of the fingers
Nail beds
Hard palate
Peri-umbilical area
The Correct Answer is C
A. Jaundice is typically not visible in the webbed areas of the fingers.
B. The nail beds are part of the skin that can show jaundice, but they may also be affected by other factors such as anemia, cyanosis, or nail polish.
C. The hard palate is a part of the oral mucosa that can show jaundice, especially in clients with dark skin tones.
D. This is not an area that the nurse should inspect to monitor for the presence of jaundice in a client who is African American and has cholecystitis. The skin can show jaundice, but it may be difficult to detect in clients with dark skin tones.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. In the oliguric phase of acute kidney injury, fluid intake may need to be restricted rather than encouraged to prevent fluid overload.
B. Hourly intake and output monitoring is crucial for managing fluid balance and assessing the progression of kidney injury. Close monitoring can help prevent fluid overload, which is a risk due to the reduced urine output. It also aids in the timely adjustment of fluid administration and the detection of any changes in the client's condition that may necessitate intervention.
C. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen are contraindicated in acute kidney injury as they can further impair renal function.
D. In the oliguric phase, protein intake may need to be restricted to reduce the workload on the kidneys and minimize azotemia. A high-protein diet can increase the burden on already compromised kidneys due to the increased production of urea, a byproduct of protein metabolism that requires excretion by the kidneys.
Correct Answer is C
Explanation
A. Orange, could also indicate dehydration, but it may also be caused by certain medications or foods, so it is not as specific as dark amber for dehydration.
B. Smoky urine is often associated with blood in the urine, which can result from various conditions but is not specific to dehydration.
C. Dehydration occurs when the body loses more fluids than it takes in, leading to a higher concentration of waste products in the urine, which gives it a dark amber color. This is because with less water to dilute them, the naturally occurring minerals and chemicals in the urine become more concentrated.
D. Green urine is not typically associated with dehydration and may indicate other underlying conditions or the presence of certain medications or foods.
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