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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View Related questions
Correct Answer is A
Explanation
Choice A rationale
Acute pancreatitis is a potential complication after cholecystectomy. The persistent upper abdominal pain radiating to the back is a classic symptom of acute pancreatitis. This condition can occur due to the migration of gallstones or other factors affecting the pancreas.
Choice B rationale
Biliary duct obstruction can cause upper abdominal pain, but it is less likely to present with pain radiating to the back. This condition typically presents with jaundice and other symptoms.
Choice C rationale
Surgical site infection can cause abdominal pain, but it is usually localized to the surgical site and does not typically radiate to the back. Other signs of infection, such as fever and redness, would also be present.
Choice D rationale
Hepatorenal failure is a severe condition that can occur in patients with liver disease, but it is not commonly associated with pain radiating to the back. It typically presents with symptoms of liver and kidney dysfunction.
Correct Answer is B
Explanation
Choice A rationale
Obtaining vital signs every 2 hours is important for monitoring the patient’s overall condition, but it is not the immediate priority following the surgical removal of glass from the eye.
Choice B rationale
Providing an eye shield to be worn while sleeping is crucial to protect the eye from injury and promote healing after the surgical removal of glass. This intervention helps prevent accidental rubbing or pressure on the eye.
Choice C rationale
Teaching a family member to administer eye drops is important for ongoing care, but it is not the immediate priority following the procedure. The immediate focus should be on protecting the eye and ensuring proper healing.
Choice D rationale
Encouraging deep breathing and coughing exercises is important for preventing respiratory complications, but it is not directly related to the immediate care of the eye following the surgical removal of glass.