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 A
Explanation
Choice A rationale
pH 7.49, PCO₂ 45 mm Hg, HCO₃ 32 mEq/L (32 mmol/L), PO₂ 90 mm Hg indicates metabolic alkalosis. The elevated pH and HCO₃ levels are consistent with this condition.
Choice B rationale
pH 7.30, PCO₂ 20 mm Hg, HCO₃ 22 mEq/L (22 mmol/L), PO₂ 85 mm Hg indicates metabolic acidosis with respiratory compensation, not metabolic alkalosis.
Choice C rationale
pH 7.46, PCO₂ 55 mm Hg, HCO₃ 36 mEq/L (36 mmol/L), PO₂ 95 mm Hg indicates metabolic alkalosis with respiratory compensation. However, the pH is slightly lower than in Choice A, making Choice A more indicative of metabolic alkalosis.
Choice D rationale
pH 7.29, PCO₂ 35 mm Hg, HCO₃ 25 mEq/L (25 mmol/L), PO₂ 99 mm Hg indicates metabolic acidosis, not metabolic alkalosis.
Correct Answer is A
Explanation
Choice A rationale
Postural drainage involves placing the client in various positions to facilitate the drainage of secretions from different parts of the lungs. Typically, the client may be placed in five positions: head down, prone, right and left lateral, and sitting upright.
Choice B rationale
Performing postural drainage immediately after meals is not recommended as it can cause nausea, vomiting, and aspiration. It is best to perform the procedure before meals.
Choice C rationale
Obtaining an arterial blood gas (ABG) prior to the procedure is not a standard requirement for postural drainage. ABGs are typically obtained to assess the client’s respiratory status but are not necessary for the procedure itself.
Choice D rationale
Instructing the client to breathe shallow and fast is not appropriate for postural drainage. The client should be encouraged to breathe slowly and deeply to help keep the airways open and facilitate the drainage of secretions.