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A client 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?

A.

Flatulence.

B.

Amber urine.

C.

Belching.

D.

Yellow sclera.

Answer and Explanation

The Correct Answer is D

Choice A rationale

 

Flatulence is not a specific indicator of a serious complication related to a gallstone lodged in the common bile duct.

 

Choice B rationale

 

Amber urine is normal and does not indicate a serious complication.

 

Choice C rationale

 

Belching is not a specific indicator of a serious complication related to a gallstone lodged in the common bile duct.

 

Choice D rationale

 

Yellow sclera indicates jaundice, which is a sign of bile duct obstruction and requires immediate medical attention.

 


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View Related questions

Correct Answer is D

Explanation

Choice A rationale

Counting the apical and radial pulses simultaneously is important for assessing pulse deficits, but it is not the most critical assessment for a client receiving hydromorphone.

Choice B rationale

Measuring the client’s capillary glucose level is important for clients with diabetes, but it is not directly related to the administration of hydromorphone.

Choice C rationale

Observing for edema around the ankles is important for assessing fluid retention, but it is not the most critical assessment for a client receiving hydromorphone.

Choice D rationale

Auscultating the client’s bowel sounds is crucial because hydromorphone is a potent opioid analgesic that can slow peristalsis and frequently causes constipation. Monitoring bowel sounds helps prevent complications such as bowel obstruction. .

Correct Answer is A

Explanation

Choice A rationale

Irregular rapid heart rate (tachycardia) is a serious side effect of albuterol and warrants immediate intervention. Albuterol is a beta-2 agonist that can cause stimulation of beta-1 receptors in the heart, leading to tachycardia and potential arrhythmias.

Choice B rationale

Uncontrollable shaking (tremors) is a common side effect of albuterol due to its stimulation of beta-2 receptors in skeletal muscles. While uncomfortable, it is not typically life-threatening.

Choice C rationale

Increased anxiety can occur with albuterol use due to its stimulant effects on the central nervous system. However, it is not as immediately dangerous as tachycardia.

Choice D rationale

Throat irritation is a minor side effect of albuterol and does not require immediate intervention.

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