A nurse is reinforcing teaching with a client who has cholelithiasis and is scheduled for an endoscopic retrograde cholangiopancreatography. Which of the following statements made by the client indicates an understanding of the teaching?

"They are going to examine my gallbladder and ducts."

"I'll have an endoscope put down my throat so they can see my gallbladder."

"Soon those shock waves will get rid of my gallstones."

"They'll put medication into my gallbladder to dissolve the stones."

Answer and Explanation

The Correct Answer is B

A.   This is partially correct but lacks the detail that the examination is done via an endoscope through the throat.
B.   An endoscopic retrograde cholangiopancreatography (ERCP) involves the use of an endoscope to visualize and treat problems in the bile ducts, gallbladder, and pancreas.
C.   This statement reflects a misunderstanding of the procedure, as ERCP does not involve shock waves to treat gallstones.
D.   This statement also reflects a misunderstanding, as ERCP is primarily a diagnostic procedure and does not involve direct medication delivery to the gallbladder.

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Correct Answer is C

Explanation

A. Daily weight monitoring is important for assessing fluid status but may not provide real-time information about fluid balance changes.
B. Vital signs are important for overall assessment but may not specifically address the nursing diagnosis of Excess Fluid Volume unless there are significant changes indicative of fluid overload or dehydration.
C. Monitoring intake and output provides direct information about fluid balance and renal function, helping to identify trends and assess the effectiveness of interventions aimed at managing fluid volume.
D. Skin turgor assessment is useful for evaluating hydration status but may not provide comprehensive data on fluid volume excess alone.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Explanation

The nurse should prioritize the client's immediate clinical needs based on the assessment data provided.

The first action should be to address the client's agitation, which is a sign of distress and can lead to safety issues. Therefore, the nurse should first address the client's "fall precautions" to ensure safety and prevent potential harm due to the client's disorientation and agitation.

Following this, the nurse should address the client's "urine collection" for urinalysis and culture and sensitivity (C&S), as it is critical to identify the cause of the client's febrile state and incontinence of foul-smelling urine, which could indicate an infection. This will allow for appropriate antibiotic therapy to be administered based on the sensitivity results.

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A nurse is reinforcing teaching with a client who has cholelithiasis and is scheduled for an endoscopic retrograde cholangiopancreatography. Which of the following statements made by the client indicates an understanding of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nursing diagnosis of Excess Fluid Volume is made for a patient with chronic kidney disease. Which of the following data is most important for the nurse to collect for this patient based on the nursing diagnosis?

Correct Answer is C

Explanation

A nurse is assisting in the care of a client in the emergency department (ED). Exhibits Complete the following sentence by using the list of options. The nurse should first address the client’s followed by the client’s

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Explanation

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