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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 A

Explanation

Choice A rationale

Suctioning to clear secretions from the airway is the first intervention to implement. The client’s weak cough effort and use of accessory muscles to breathe suggest the presence of retained respiratory secretions, which can impair breathing and lead to further respiratory compromise.

Choice B rationale

Offering a prescribed PRN analgesic is important for overall comfort but is not the most immediate intervention needed to address the client’s respiratory distress.

Choice C rationale

Obtaining arterial blood gases may provide valuable information but is not the most immediate intervention needed to address the client’s respiratory distress.

Choice D rationale

Administering a prescribed antipyretic is not the most immediate intervention needed to address the client’s respiratory distress.

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.

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