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?
Flatulence.
Amber urine.
Belching.
Yellow sclera.
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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Correct Answer is B
Explanation
Choice A rationale
Teaching anxiety reduction methods for feelings of suffocation is important but not the most immediate action needed to address the client’s respiratory symptoms.
Choice B rationale
Increasing the daily intake of oral fluids to liquefy secretions is the most important action for the nurse to instruct the client about self-care. This helps to thin the mucus, making it easier to expectorate and improving breathing.
Choice C rationale
Calling the clinic if undesirable side effects of medications occur is important but not the most immediate action needed to address the client’s respiratory symptoms.
Choice D rationale
Avoiding crowded enclosed areas to reduce pathogen exposure is important but not the most immediate action needed to address the client’s respiratory symptoms.
Correct Answer is B
Explanation
Choice A rationale
Serum blood glucose level is not directly related to the presence of purulent drainage at a wound site. While blood glucose levels can affect wound healing, they do not provide specific information about the presence of infection.
Choice B rationale
Culture for sensitive organisms is the most appropriate laboratory value to note when purulent drainage is observed. This test helps identify the specific bacteria causing the infection and determines the most effective antibiotics for treatment.
Choice C rationale
C-reactive protein (CRP) level is a marker of inflammation and can indicate the presence of an infection, but it does not provide specific information about the bacteria causing the infection.
Choice D rationale
Blood pH level is not directly related to the presence of purulent drainage at a wound site. While blood pH can be affected by severe infections, it is not a specific indicator of wound infection.