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
Reported history of alcoholism is the most important assessment finding to address before administering terbinafine HCL. Terbinafine is metabolized by the liver, and clients with a history of alcoholism may have impaired liver function, increasing the risk of hepatotoxicity. Monitoring liver function and assessing for signs of liver damage are crucial before starting treatment.
Choice B rationale
Toenails appear thick and yellow is a common symptom of fungal toenail infection, but it is not the most critical assessment finding to address before administering terbinafine HCL. The focus should be on assessing liver function.
Choice C rationale
Employed as a construction worker is not the most critical assessment finding to address before administering terbinafine HCL. While occupational exposure to fungi may be relevant, the primary concern is liver function.
Choice D rationale
White blood cell count of 8,500/mm³ (8.5 x 10⁹/L) is within the normal range and is not the most critical assessment finding to address before administering terbinafine HCL. The primary concern is liver function.
Correct Answer is A
Explanation
Choice A rationale
Isolating the client from others is the most important action to prevent the spread of COVID-19. This includes isolating the client from other clients, family, and healthcare workers not wearing proper PPE2.
Choice B rationale
Reporting the COVID-19 result to the local health department is important but not the immediate priority. Isolation takes precedence to prevent transmission.
Choice C rationale
Teaching the client to wear a mask, hand wash, and social distance is essential but secondary to immediate isolation.
Choice D rationale
Counseling family members to monitor for symptoms is important but not the immediate priority. Isolation of the client is the first step.