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 D
Explanation
Choice A rationale:
Incorrect. Open-angle glaucoma is not characterized by an abnormally small angle.
The angle in open-angle glaucoma is open, but the drainage system is not working properly. Therefore, restoring a smaller angle would not be an effective treatment goal.
Choice B rationale:
Incorrect. Eye drops used to treat open-angle glaucoma are not typically used for pain control.
While some individuals may experience mild discomfort associated with elevated eye pressure, pain is not a common symptom of open-angle glaucoma.
Additionally, eye drops used to treat glaucoma do not have anti-inflammatory properties to address swelling.
Choice C rationale:
Incorrect. While reducing excess eye pressure is an important initial goal of treatment, long-term management of open-angle glaucoma requires ongoing maintenance of normal eye pressure.
Simply reducing pressure temporarily is not sufficient to prevent vision loss.
Choice D rationale:
Correct. The primary goal of treatment for open-angle glaucoma is to maintain normal eye pressure over the long term. This is because elevated eye pressure can damage the optic nerve, leading to vision loss.
Eye drops are often used to lower eye pressure, and they typically need to be used for life to prevent vision loss.
Correct Answer is B
Explanation
Choice A rationale:
Radiation exposure to the eye is a serious condition that requires immediate medical attention. However, it is not a contraindication for ophthalmic ketorolac. In fact, ketorolac may be used to treat pain and inflammation associated with radiation exposure to the eye.
Ophthalmic ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) that works by inhibiting the production of prostaglandins, which are substances that cause inflammation and pain.
Radiation exposure can damage the cells of the eye, leading to inflammation and pain. Ketorolac can help to reduce these symptoms.
However, it is important to note that ketorolac does not address the underlying cause of radiation exposure, and further treatment may be necessary.
Choice B rationale:
Corneal abrasion is a scratch on the surface of the cornea, the clear outer layer of the eye. It is a common eye injury that can be caused by a variety of factors, such as getting poked in the eye, rubbing the eye too hard, or wearing contact lenses for too long.
Ophthalmic ketorolac is contraindicated in patients with corneal abrasions because it can delay healing and increase the risk of infection.
This is because ketorolac inhibits the production of prostaglandins, which are involved in the healing process. Prostaglandins also play a role in fighting infection.
Therefore, using ketorolac in a patient with a corneal abrasion could potentially lead to a more serious infection.
Choice C rationale:
Chemical burn to the eye is a serious injury that requires immediate medical attention. Ophthalmic ketorolac is not typically used to treat chemical burns to the eye.
This is because ketorolac is not effective in reducing inflammation caused by chemical burns. In addition, ketorolac can potentially worsen the injury by delaying healing.
Choice D rationale:
Foreign body in the eye is a common eye injury that can be caused by a variety of objects, such as dust, sand, or metal shavings. Ophthalmic ketorolac is not typically used to treat foreign bodies in the eye.
This is because ketorolac will not help to remove the foreign body from the eye. In addition, ketorolac can potentially worsen the injury by delaying healing.
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