THE CLIENT WITH CHOLECYSTITIS
1. A client has undergone a laparoscopic cholecystectomy. Which of the following
instructions should the nurse include in the discharge teaching?
1. Empty the bile bag daily.
2. If you become nauseated, breathe deeply into a paper bag.
3. Keep adhesive dressings in place for 6 weeks.
4. Report bile-colored drainage from any incision.
4. 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 to 10 days, not 6 weeks.
2. A 40-year-old client is admitted to the hospital with a diagnosis of acute cholecystitis.
The nurse should contact the physician to question which of the following orders?
1. I.V. fluid therapy of normal saline solution to be infused at 100 mL/hour until further
orders.
2. Administer morphine sulfate 10 mg I.M. every 4 hours as needed for severe
abdominal pain.
3. Nothing by mouth (NPO) until further orders.
4. Insert a nasogastric tube and connect to low intermittent suction.
2. A nurse should question the order for morphine sulfate because it is believed to
cause biliary spasm. Thus, the preferred opioid analgesic to treat cholecystitis is
meperidine (Demerol). Elderly clients should not be given meperidine because of the
risk of acute confusion and seizures in this population. An alternative pain medication
will be necessary. I.V. fluid therapy is used to maintain fluid and electrolyte balance that
may result from NPO status and gastric suctioning. NPO status and gastric
decompression prevent further gallbladder stimulation.
3. A client is admitted to the hospital with a diagnosis of cholecystitis from cholelithiasis.
The client has severe abdominal pain, nausea, and has vomited several times. Based
on these data, which nursing diagnosis would have the highest priority for intervention
at this time?
1. Anxiety related to severe abdominal discomfort.
2. Deficient fluid volume related to vomiting.
3. Pain related to gallbladder inflammation.
4. Imbalanced nutrition: Less than body requirements related to vomiting.
3. 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 and vomiting, is caused by
biliary spasm. Opioid analgesics are given to relieve the severe pain and spasm of
cholecystitis. Relief of pain may decrease nausea and vomiting and thereby decrease
the client's likelihood of developing further complications, such as deficient fluid volume
and imbalanced nutrition. There are no data to suggest that the client is anxious.
4. A client's stools are light gray in color. The nurse should assess the client further for
which of the following? Select all that apply.
1. Intolerance to fatty foods.
2. Fever.
3. Jaundice.
,4. Respiratory distress.
5. Pain at McBurney's point.
6. Peptic ulcer disease.
1, 2, 3. Bile is created in the liver, stored in the gallbladder, and 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, and nausea or right upper quadrant pain after a fatty meal. Pain at McBurney's
point lies between the umbilicus and right iliac crest and is associated with appendicitis.
A bleeding ulcer produces black, tarry stools. Respiratory distress is not a symptom of
cholelithiasis.
5. A client who has been scheduled to have a choledocholithotomy expresses anxiety
about having surgery. Which nursing intervention would be the most appropriate to
achieve the outcome of anxiety reduction?
1. Providing the client with information about what to expect postoperatively.
2. Telling the client it is normal to be afraid.
3. Reassuring the client by telling her that surgery is a common procedure.
4. Stressing the importance of following the physician's instructions after surgery.
1. Providing information can help to answer the client's questions and decrease anxiety.
Fear of the unknown can increase anxiety. Telling the client not to be afraid, that the
procedure is common, or to follow her physician's orders will not necessarily decrease
anxiety.
6. A client has an open cholecystectomy with bile duct exploration. Following surgery,
the client has a T-tube. To evaluate the effectiveness of the T-tube, the nurse should:
1. Irrigate the tube with 20 mL of normal saline every 4 hours.
2. Unclamp the T-tube and empty the contents every day.
3. Assess the color and amount of drainage every shift.
4. Monitor the multiple incision sites for bile drainage.
3. A T-tube is inserted in the common bile duct to maintain patency until edema from the
duct exploration subsides. The bile color should be gold to dark green and the amount
of drainage should be closely monitored to ensure tube patency. Irrigation is not
routinely done, unless ordered using a smaller volume of fluid. The T-tube is not
clamped in the early post-op period to allow for continuous drainage. An open
cholecystectomy has one right subcostal incision, whereas a laparoscopic
cholecystectomy has multiple small incisions.
7. At 8 a.m., the nurse reviews the amount of T-tube drainage for a client who
underwent an open cholecystectomy yesterday. After reviewing the output record (see
chart), the nurse should:
Output Record of Date T-tube
12 pm - 50 mL, 4 pm - 60 mL, 8 pm - 60 mL, 1 2 am - 70 mL, 4 am - 70 mL, 8 am - 10
mL
1. Report the 24-hour drainage amount at 12 noon.
2. Clamp the T-tube.
, 3. Evaluate the tube for patency.
4. Irrigate the T-tube.
3. The T-tube should drain approximately 300 to 500 mL in the first 24 hours and after 3
to 4 days the amount should decrease to less than 200 mL in 24 hours. With the sudden
decrease in drainage at 8 a.m., the nurse should immediately assess the tube for
obstruction of flow that can be caused by kinks in the tube or the client lying on the tube.
Drainage color must also be assessed for signs of bleeding. The tube should not be
irrigated or clamped without an order.
8. The nurse measures the amount of bile drainage from a T-tube and records it by
which one of the following methods?
1. Adding it to the client's urine output.
2. Charting it separately on the output record.
3. Adding it to the amount of wound drainage.
4. Subtracting it from the total intake for each day.
2. T-tube bile drainage is recorded separately on the output record. Adding the T-tube
drainage to the urine output or wound drainage makes it difficult to accurately determine
the amounts of bile, urine, or drainage. The client's total intake will be incorrect if
drainage is subtracted from it.
9. After a cholecystectomy, the client is to follow a low-fat diet. Which of the following
foods would be most appropriate to include in a low-fat diet?
1. Cheese omelet.
2. Peanut butter.
3. Ham salad sandwich.
4. Roast beef.
4. Lean meats, such as beef, lamb, veal, and well-trimmed lean ham and pork, are low
in fat. Rice, pasta, and vegetables are low in fat when not served with butter, cream, or
sauces. Fruits are low in fat. The amount of fat allowed in a client's diet after a
cholecystectomy will depend on the client's ability to tolerate fat. Typically, the client
does not require a special diet but is encouraged to avoid excessive fat intake. A cheese
omelet and peanut butter have high fat content. Ham salad is high in fat from the fat in
salad dressing.
10. A client with cholecystitis continues to have severe right upper quadrant pain. The
nurse obtains the following vital signs: temperature 38.4° C; pulse 114; respirations 22;
blood pressure 142/90. Using the SBAR (Situation-Background-Assessment-
Recommendation) technique for communication, the nurse recommends to the primary
care provider for the client to receive:
1. Hydromorphone (Dilaudid) I.V.
2. Diltiazem (Cardizem) PO.
3. Meperidine (Demerol) I.M.
4. Promethazine (Phenergan).
1. Dilaudid should be considered for pain management. It should be administered
intravenously for rapid action to address the severe pain the client is experiencing.
Intramuscular injections are painful and slower acting. Since meperidine's toxic
metabolite can cause seizures, it is no longer the treatment choice for pain. Diltiazem, a
calcium channel blocker, is not indicated. Elevation of heart rate and blood pressure are
likely due to pain and fever. Phenergan is used to treat nausea.
1. A client has undergone a laparoscopic cholecystectomy. Which of the following
instructions should the nurse include in the discharge teaching?
1. Empty the bile bag daily.
2. If you become nauseated, breathe deeply into a paper bag.
3. Keep adhesive dressings in place for 6 weeks.
4. Report bile-colored drainage from any incision.
4. 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 to 10 days, not 6 weeks.
2. A 40-year-old client is admitted to the hospital with a diagnosis of acute cholecystitis.
The nurse should contact the physician to question which of the following orders?
1. I.V. fluid therapy of normal saline solution to be infused at 100 mL/hour until further
orders.
2. Administer morphine sulfate 10 mg I.M. every 4 hours as needed for severe
abdominal pain.
3. Nothing by mouth (NPO) until further orders.
4. Insert a nasogastric tube and connect to low intermittent suction.
2. A nurse should question the order for morphine sulfate because it is believed to
cause biliary spasm. Thus, the preferred opioid analgesic to treat cholecystitis is
meperidine (Demerol). Elderly clients should not be given meperidine because of the
risk of acute confusion and seizures in this population. An alternative pain medication
will be necessary. I.V. fluid therapy is used to maintain fluid and electrolyte balance that
may result from NPO status and gastric suctioning. NPO status and gastric
decompression prevent further gallbladder stimulation.
3. A client is admitted to the hospital with a diagnosis of cholecystitis from cholelithiasis.
The client has severe abdominal pain, nausea, and has vomited several times. Based
on these data, which nursing diagnosis would have the highest priority for intervention
at this time?
1. Anxiety related to severe abdominal discomfort.
2. Deficient fluid volume related to vomiting.
3. Pain related to gallbladder inflammation.
4. Imbalanced nutrition: Less than body requirements related to vomiting.
3. 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 and vomiting, is caused by
biliary spasm. Opioid analgesics are given to relieve the severe pain and spasm of
cholecystitis. Relief of pain may decrease nausea and vomiting and thereby decrease
the client's likelihood of developing further complications, such as deficient fluid volume
and imbalanced nutrition. There are no data to suggest that the client is anxious.
4. A client's stools are light gray in color. The nurse should assess the client further for
which of the following? Select all that apply.
1. Intolerance to fatty foods.
2. Fever.
3. Jaundice.
,4. Respiratory distress.
5. Pain at McBurney's point.
6. Peptic ulcer disease.
1, 2, 3. Bile is created in the liver, stored in the gallbladder, and 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, and nausea or right upper quadrant pain after a fatty meal. Pain at McBurney's
point lies between the umbilicus and right iliac crest and is associated with appendicitis.
A bleeding ulcer produces black, tarry stools. Respiratory distress is not a symptom of
cholelithiasis.
5. A client who has been scheduled to have a choledocholithotomy expresses anxiety
about having surgery. Which nursing intervention would be the most appropriate to
achieve the outcome of anxiety reduction?
1. Providing the client with information about what to expect postoperatively.
2. Telling the client it is normal to be afraid.
3. Reassuring the client by telling her that surgery is a common procedure.
4. Stressing the importance of following the physician's instructions after surgery.
1. Providing information can help to answer the client's questions and decrease anxiety.
Fear of the unknown can increase anxiety. Telling the client not to be afraid, that the
procedure is common, or to follow her physician's orders will not necessarily decrease
anxiety.
6. A client has an open cholecystectomy with bile duct exploration. Following surgery,
the client has a T-tube. To evaluate the effectiveness of the T-tube, the nurse should:
1. Irrigate the tube with 20 mL of normal saline every 4 hours.
2. Unclamp the T-tube and empty the contents every day.
3. Assess the color and amount of drainage every shift.
4. Monitor the multiple incision sites for bile drainage.
3. A T-tube is inserted in the common bile duct to maintain patency until edema from the
duct exploration subsides. The bile color should be gold to dark green and the amount
of drainage should be closely monitored to ensure tube patency. Irrigation is not
routinely done, unless ordered using a smaller volume of fluid. The T-tube is not
clamped in the early post-op period to allow for continuous drainage. An open
cholecystectomy has one right subcostal incision, whereas a laparoscopic
cholecystectomy has multiple small incisions.
7. At 8 a.m., the nurse reviews the amount of T-tube drainage for a client who
underwent an open cholecystectomy yesterday. After reviewing the output record (see
chart), the nurse should:
Output Record of Date T-tube
12 pm - 50 mL, 4 pm - 60 mL, 8 pm - 60 mL, 1 2 am - 70 mL, 4 am - 70 mL, 8 am - 10
mL
1. Report the 24-hour drainage amount at 12 noon.
2. Clamp the T-tube.
, 3. Evaluate the tube for patency.
4. Irrigate the T-tube.
3. The T-tube should drain approximately 300 to 500 mL in the first 24 hours and after 3
to 4 days the amount should decrease to less than 200 mL in 24 hours. With the sudden
decrease in drainage at 8 a.m., the nurse should immediately assess the tube for
obstruction of flow that can be caused by kinks in the tube or the client lying on the tube.
Drainage color must also be assessed for signs of bleeding. The tube should not be
irrigated or clamped without an order.
8. The nurse measures the amount of bile drainage from a T-tube and records it by
which one of the following methods?
1. Adding it to the client's urine output.
2. Charting it separately on the output record.
3. Adding it to the amount of wound drainage.
4. Subtracting it from the total intake for each day.
2. T-tube bile drainage is recorded separately on the output record. Adding the T-tube
drainage to the urine output or wound drainage makes it difficult to accurately determine
the amounts of bile, urine, or drainage. The client's total intake will be incorrect if
drainage is subtracted from it.
9. After a cholecystectomy, the client is to follow a low-fat diet. Which of the following
foods would be most appropriate to include in a low-fat diet?
1. Cheese omelet.
2. Peanut butter.
3. Ham salad sandwich.
4. Roast beef.
4. Lean meats, such as beef, lamb, veal, and well-trimmed lean ham and pork, are low
in fat. Rice, pasta, and vegetables are low in fat when not served with butter, cream, or
sauces. Fruits are low in fat. The amount of fat allowed in a client's diet after a
cholecystectomy will depend on the client's ability to tolerate fat. Typically, the client
does not require a special diet but is encouraged to avoid excessive fat intake. A cheese
omelet and peanut butter have high fat content. Ham salad is high in fat from the fat in
salad dressing.
10. A client with cholecystitis continues to have severe right upper quadrant pain. The
nurse obtains the following vital signs: temperature 38.4° C; pulse 114; respirations 22;
blood pressure 142/90. Using the SBAR (Situation-Background-Assessment-
Recommendation) technique for communication, the nurse recommends to the primary
care provider for the client to receive:
1. Hydromorphone (Dilaudid) I.V.
2. Diltiazem (Cardizem) PO.
3. Meperidine (Demerol) I.M.
4. Promethazine (Phenergan).
1. Dilaudid should be considered for pain management. It should be administered
intravenously for rapid action to address the severe pain the client is experiencing.
Intramuscular injections are painful and slower acting. Since meperidine's toxic
metabolite can cause seizures, it is no longer the treatment choice for pain. Diltiazem, a
calcium channel blocker, is not indicated. Elevation of heart rate and blood pressure are
likely due to pain and fever. Phenergan is used to treat nausea.
