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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 C

Explanation

Choice A rationale

Attaching humidification to oxygen delivery can help with comfort but is not the immediate priority in assessing the client’s respiratory status.

Choice B rationale

Coaching through using huff coughing is a useful technique for clearing secretions but should follow the assessment of the client’s oxygenation status.

Choice C rationale

Obtaining a pulse oximetry reading is the next immediate action after positioning the client upright. It provides essential information about the client’s oxygen saturation and helps guide further interventions.

Choice D rationale

Providing a nebulizer breathing treatment can help relieve symptoms but should be based on the assessment of the client’s oxygenation status.

Correct Answer is D

Explanation

Choice A rationale

Storing the medication at room temperature is appropriate for ipratropium inhalers. This ensures the medication remains effective and safe for use.

Choice B rationale

Attaching a spacer device to the inhaler is recommended for patients using ipratropium inhalers. A spacer helps deliver the medication more effectively to the lungs and reduces the risk of side effects.

Choice C rationale

Rinsing the mouth after each use of the inhaler is a good practice to prevent oral thrush and other side effects. It is a recommended step in the proper use of inhalers.

Choice D rationale

Priming the inhaler with 7 pumps is excessive. Typically, inhalers need to be primed with 2-4 pumps before first use or if they haven’t been used for a while. Over-priming can waste medication and indicate a need for additional teaching.

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