NCLEX-RN Review - Test 7
- The Client with Biliary Tract Disorders
A client has undergone a laparoscopic cholecystectomy. Which instruction
should the nurse include in the discharge teaching?
1. Empty the bile bag daily.
2. Breath deeply into a paper bag when nauseated.
3. Keep adhesive dressings in place for 6 weeks.
4. Report bile-colored drainage from any incision. - ANS: 4
4. Report bile-colored drainage from any incision.
There should be no bile-colored drainage coming from any of the incisions
postoperatively.
A laparoscopic cholecystectomy does not involve a bile bag. Breathing
deeply into a paper bag will prevent a person from passing out due to
hyperventilation; it does not alleviate nausea. If the adhesive dressings have
not already fallen off, they are removed by the surgeon in 7-10 days, not 6
weeks.
A client with acute cholecystitis has severe pain. Which prescription will be
most effective in relieving the pain?
1. infusing normal saline solution at 100mL/hr
2. administering morphine sulfate 10mg IM every 3-4 hours
3. receiving nothing by mouth (NPO)
4. having a nasogastric tube connected to low intermittent suction - ANS: 2
2. administering morphine sulfate 10mg IM every 3-4 hours
The client is in severe pain & the nurse should administer the morphine to
relieve the pain.
The client will receive IV fluids to maintain fluid & electrolyte balance, but
that will not relieve the pain. The client may be NPO & have a NG tube to
promote gastric decompression to prevent further gallbladder stimulation,
but these are not sufficient to manage pain.
, A client is admitted to the hospital with a diagnosis of cholecystitis. The
client has severe abdominal pain & nausea & has vomited o120mL. Based
on these date, which nursing action would have the highest priority at this
time?
1. Manage anxiety.
2. Restore fluid loss.
3. Manage the pain.
4. Replace nutritional loss. - ANS: 3
3. Manage the pain.
The priority for nursing care at this time is to decrease the client's severe
abdominal pain.
The pain, which is frequently accompanied by nausea & vomiting, is caused
by biliary spasm. Opioid analgesics are given to relieve the severe pain &
spasm of cholecystitis. Relief of pain may decrease nausea & vomiting &
thereby decrease the client's likelihood of developing further complications,
such as severe fluid loss & inadequate nutrition. There are no data to
suggest that the client is anxious.
The client's stools are light gray in color. What additional information
should the nurse obtain from the client? Select all that apply.
1. intolerance of fatty foods
2. fever
3. jaundice
4. respiratory distress
5. pain at McBurney's point
6. bleeding ulcer - ANS: 1, 2, 3
1. intolerance of fatty foods
2. fever
3. jaundice
Bile is created in the liver, stored in the gallbladder & released into the
duodenum, giving stool its brown color. A bile duct obstruction can cause
pale-colored stools. Other symptoms associated with cholelithiasis are right
upper quadrant tenderness, fever from inflammation or infection, jaundice
from elevated serum bilirubin levels & nausea or right upper quadrant pain
after a fatty meal.
- The Client with Biliary Tract Disorders
A client has undergone a laparoscopic cholecystectomy. Which instruction
should the nurse include in the discharge teaching?
1. Empty the bile bag daily.
2. Breath deeply into a paper bag when nauseated.
3. Keep adhesive dressings in place for 6 weeks.
4. Report bile-colored drainage from any incision. - ANS: 4
4. Report bile-colored drainage from any incision.
There should be no bile-colored drainage coming from any of the incisions
postoperatively.
A laparoscopic cholecystectomy does not involve a bile bag. Breathing
deeply into a paper bag will prevent a person from passing out due to
hyperventilation; it does not alleviate nausea. If the adhesive dressings have
not already fallen off, they are removed by the surgeon in 7-10 days, not 6
weeks.
A client with acute cholecystitis has severe pain. Which prescription will be
most effective in relieving the pain?
1. infusing normal saline solution at 100mL/hr
2. administering morphine sulfate 10mg IM every 3-4 hours
3. receiving nothing by mouth (NPO)
4. having a nasogastric tube connected to low intermittent suction - ANS: 2
2. administering morphine sulfate 10mg IM every 3-4 hours
The client is in severe pain & the nurse should administer the morphine to
relieve the pain.
The client will receive IV fluids to maintain fluid & electrolyte balance, but
that will not relieve the pain. The client may be NPO & have a NG tube to
promote gastric decompression to prevent further gallbladder stimulation,
but these are not sufficient to manage pain.
, A client is admitted to the hospital with a diagnosis of cholecystitis. The
client has severe abdominal pain & nausea & has vomited o120mL. Based
on these date, which nursing action would have the highest priority at this
time?
1. Manage anxiety.
2. Restore fluid loss.
3. Manage the pain.
4. Replace nutritional loss. - ANS: 3
3. Manage the pain.
The priority for nursing care at this time is to decrease the client's severe
abdominal pain.
The pain, which is frequently accompanied by nausea & vomiting, is caused
by biliary spasm. Opioid analgesics are given to relieve the severe pain &
spasm of cholecystitis. Relief of pain may decrease nausea & vomiting &
thereby decrease the client's likelihood of developing further complications,
such as severe fluid loss & inadequate nutrition. There are no data to
suggest that the client is anxious.
The client's stools are light gray in color. What additional information
should the nurse obtain from the client? Select all that apply.
1. intolerance of fatty foods
2. fever
3. jaundice
4. respiratory distress
5. pain at McBurney's point
6. bleeding ulcer - ANS: 1, 2, 3
1. intolerance of fatty foods
2. fever
3. jaundice
Bile is created in the liver, stored in the gallbladder & released into the
duodenum, giving stool its brown color. A bile duct obstruction can cause
pale-colored stools. Other symptoms associated with cholelithiasis are right
upper quadrant tenderness, fever from inflammation or infection, jaundice
from elevated serum bilirubin levels & nausea or right upper quadrant pain
after a fatty meal.
