A patient with cholelithiasis has a gallstone lodged in the common bile duct and is unable to eat or drink without becoming nauseated and vomiting.
Which finding should the nurse report to the healthcare provider?
Amber urine.
Belching.
Flatulence.
Yellow sclera.
The Correct Answer is D
Choice A rationale:
Amber urine can be a sign of dehydration, but it is not specific to cholelithiasis with a gallstone lodged in the common bile duct.
While it's important to monitor hydration status in patients with nausea and vomiting, amber urine alone would not be the most urgent finding to report to the healthcare provider in this context.
Choice B rationale:
Belching is a common symptom of gastrointestinal disorders, but it is not specific to cholelithiasis with a gallstone obstruction. It can be caused by various factors, such as swallowing air, eating too quickly, or drinking carbonated beverages.
While belching might be a symptom the nurse documents, it would not be the most concerning finding to report immediately.
Choice C rationale:
Flatulence is another common gastrointestinal symptom that can have various causes, including dietary choices, bacterial fermentation in the intestines, and certain medications.
It is not specific to cholelithiasis with a gallstone obstruction and would not be the most relevant finding to prioritize reporting.
Choice D rationale:
Yellow sclera, also known as jaundice, is a significant finding that strongly suggests cholestasis, which is the obstruction of bile flow.
Bile, a fluid produced by the liver, aids in digestion and gives stool its brownish color.
When bile flow is obstructed, as in the case of a gallstone lodged in the common bile duct, bilirubin (a component of bile) builds up in the bloodstream and tissues, leading to yellowing of the skin and sclera (the whites of the eyes).
This is a crucial finding to report to the healthcare provider because it indicates a worsening of the patient's condition and the need for prompt intervention to address the obstruction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale for Choice A:
Serum Helicobacter pylori (H. pylori) antibody results are not directly relevant to the diagnosis or management of acute pancreatitis. While H. pylori infection can cause gastritis and peptic ulcers, it is not a common cause of pancreatitis.
Urine output amounts are important to monitor in patients with pancreatitis to assess for dehydration and kidney function. However, they are not as specific to the diagnosis of pancreatitis as other findings.
Rationale for Choice B:
Reports of chronic constipation are not typically associated with acute pancreatitis.
Serum gastrin levels are used to diagnose conditions such as Zollinger-Ellison syndrome, which is characterized by excessive acid production in the stomach. They are not relevant to the diagnosis of pancreatitis.
Rationale for Choice C:
Severity of nausea and vomiting are key symptoms of pancreatitis. The severity of these symptoms can help to gauge the severity of the pancreatitis and guide treatment decisions.
Serum amylase results are a highly sensitive and specific marker for pancreatitis. Elevated levels of amylase in the blood strongly suggest the presence of pancreatitis.
Rationale for Choice D:
Presence of bowel sounds can be variable in patients with pancreatitis and are not always reliable indicators of the severity of the condition.
Degree of abdominal pain is a subjective symptom that can be difficult to assess accurately. While it is an important symptom of pancreatitis, it is not as objective as other findings such as serum amylase levels.
Therefore, the most valuable information to report to the healthcare provider in this case is the severity of nausea and vomiting and serum amylase results.
Correct Answer is ["C","D"]
Explanation
Choice A rationale:
PaCO2 55 mm Hg on a blood gas indicates ineffective treatment. Normal PaCO2 levels range from 35-45 mm Hg.
Elevated PaCO2 (hypercapnia) suggests that the lungs are not effectively removing carbon dioxide from the body. This can be due to various factors, including:
Incomplete resolution of pneumonia Airway obstruction
Impaired respiratory muscle function
Choice B rationale:
Rhonchi in the right lung indicates ineffective treatment.
Rhonchi are coarse, rattling sounds heard in the lungs during auscultation.
They are often associated with mucus accumulation in the airways, which can occur in pneumonia.
The presence of rhonchi suggests that inflammation and mucus production persist, despite antibiotic and respiratory therapy.
Choice C rationale:
Oxygen saturation greater than 94% indicates effective treatment. Normal oxygen saturation levels are typically 95% or higher.
A saturation of 94% or above suggests that the lungs are able to effectively oxygenate the blood. This is a positive sign that the pneumonia is responding to treatment.
Choice D rationale:
Client ambulates without shortness of breath indicates effective treatment. Shortness of breath (dyspnea) is a common symptom of pneumonia.
It occurs when the lungs are unable to provide enough oxygen to the body, leading to a feeling of breathlessness.
The ability to ambulate without shortness of breath suggests that the pneumonia has improved and that the lungs are functioning more effectively.
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