NCLEX-RN Review - Test 7 - The Client with

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?

• Empty the bile bag daily.
• Breath deeply into a paper bag when nauseated.
• Keep adhesive dressings in place for 6 weeks.
• Report bile-colored drainage from any incision.

ANS: 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?

• infusing normal saline solution at 100mL/hr
• administering morphine sulfate 10mg IM every 3-4 hours
• receiving nothing by mouth (NPO)
• having a nasogastric tube connected to low intermittent suction

ANS: 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?

• Manage anxiety.
• Restore fluid loss.
• Manage the pain.
• Replace nutritional loss.

ANS: 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.

• intolerance of fatty foods
• fever
• jaundice
• respiratory distress
• pain at McBurney's point
• bleeding ulcer

ANS: 1, 2, 3

• intolerance of fatty foods
• fever

• 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.

Pain as McBurney's point lies between the umbilicus & right iliac crest & is associated with appendicitis.A bleeding ulcer produces black, tarry stools. Respiratory distress is not a symptom of cholelithiasis.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?

• providing the client with information about what to expect postoperatively
• telling the client not to be afraid
• reassuring the client by saying that surgery is a common procedure
• stressing the importance of following the health care provider's instructions after surgery

ANS: 1

• providing the client with information about what to expect postoperatively

Providing information can help to answer the client's questions & decrease anxiety. Fear of the unknown can increase anxiety.

Telling the client not to be afraid, that the procedure is common, or to follow the HCP's prescriptions will not necessarily decrease anxiety.A client has an open cholecystectomy with bile duct exploration. Following surgery, the client has a T tube. What should the nurse do to determine the effectiveness of the T tube?

• Irrigate the tube with 20mL of normal saline every 4 hours.
• Unclamp the T tube & empty the contents every day.
• Assess the color & amount of drainage every shift.
• Monitor the incision sites for bile drainage.

ANS: 3

• Assess the color & amount of drainage every shift.

A T tube is inserted in the common bile duct to maintain patency when there is a likelihood of edema.The tube remains in place until edema from the duct exploration subsides. The bile color should be gold to dark green & the amount of drainage should be closely monitored to ensure tube patency.

Irrigation is not routinely done, unless prescribed using a smaller volume of fluid. The T tube is not clamped in the early postop period to allow for continuous drainage. An open cholecystectomy has one right subcostal incision, whereas a laparoscopic cholecystectomy has multiple small incisions.At 0800, 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), what should the nurse do next?

Output Record Time T-Tube 1200 50mL 1600 60mL 2000 60mL 0000 70mL 0400 70mL 0800 10mL

• Report the 24-hour drainage amount at 1200.
• Clamp the T tube.
• Evaluate the tube for patency.
• Irrigate the T tube.

ANS: 3

• Evaluate the tube for patency.

The T tube should drain approximately 300-500mL in the first 24 hours & after 3-4 days the amount should decrease to <200mL in 24 hours. With the sudden decrease in drainage at 0800, 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 a prescription.