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","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.
Correct Answer is B
Explanation
Choice A rationale:
Total protein is a measure of the overall protein content in the blood. It includes albumin and globulin.
While it can be helpful in assessing nutritional status and liver function, it is not directly relevant to the client's current symptoms of pallor and fatigue.
Decreased total protein can indicate malnutrition or liver disease, but these conditions would not typically cause the specific symptoms of pallor and fatigue.
Therefore, total protein is not the most important laboratory value to review in this case.
Choice B rationale:
Hemoglobin is the protein in red blood cells that carries oxygen throughout the body.
Paleness (pallor) is a common sign of anemia, which is a condition characterized by a low hemoglobin level. Fatigue is also a common symptom of anemia, as the body's tissues are not receiving enough oxygen.
Diclofenac, a non-steroidal anti-inflammatory drug (NSAID), can cause gastrointestinal bleeding, which can lead to anemia. Therefore, it is essential for the nurse to review the client's hemoglobin level to assess for potential anemia.
Choice C rationale:
Glucose is a type of sugar that the body uses for energy.
Abnormal glucose levels can cause various symptoms, including fatigue. However, glucose levels would not typically cause pallor.
Additionally, there is no indication in the question stem that the client has any risk factors for diabetes or other disorders that affect glucose metabolism.
Therefore, glucose is not the most likely cause of the client's symptoms.
Choice D rationale:
Sodium is an electrolyte that helps regulate fluid balance in the body.
Abnormal sodium levels can cause various symptoms, including fatigue and weakness. However, sodium levels would not typically cause pallor.
Additionally, there is no indication in the question stem that the client has any risk factors for electrolyte imbalances. Therefore, sodium is not the most likely cause of the client's symptoms.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today