A client diagnosed with cholecystitis reports right upper quadrant pain that radiates to the right shoulder. Which of the following interventions is the priority for the nurse to implement?

Administer IV ketorolac.

Report findings to healthcare provider.

Offer a high-calorie, high-fat meal.

Assess the pain level.

Answer and Explanation

The Correct Answer is D

Choice A reason: This is incorrect because administering IV ketorolac is not a priority intervention for a client with cholecystitis. Ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) that can cause gastrointestinal bleeding and kidney damage, which are contraindicated in cholecystitis. The nurse should administer analgesics as prescribed, but only after assessing the pain level and severity.

Choice B reason: This is incorrect because reporting findings to healthcare provider is not a priority intervention for a client with cholecystitis. The nurse should communicate with the healthcare provider about the client's condition and treatment plan, but only after assessing the pain level and other vital signs.

Choice C reason: This is incorrect because offering a high-calorie, high-fat meal is not an intervention for a client with cholecystitis, but a potential trigger. High-fat foods can stimulate the gallbladder to contract and cause more pain and inflammation. The nurse should advise the client to avoid fatty foods and follow a low-fat diet.

Choice D reason: This is the correct answer because assessing the pain level is a priority intervention for a client with cholecystitis. Pain is the most common symptom of cholecystitis and can indicate the severity and complications of the condition. The nurse should assess the pain level using a numeric or descriptive scale, and monitor for changes in location, intensity, and duration.

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Correct Answer is A

Explanation

Choice A Reason: This is the correct choice. Washing towels, sheets, and pillowcases is a home care instruction that the nurse will offer to the client, as it prevents reinfection and transmission of bacteria or viruses. The client has conjunctivitis, which is inflammation of the conjunctiva or thin membrane that covers the white part of the eye and lines the eyelids. It can be caused by bacteria, viruses, allergies, or irritants.

Choice B Reason: This is an incorrect choice. Using antifungal drops 3 times a day is not a home care instruction that the nurse will offer to the client, as it is not effective for conjunctivitis. Antifungal drops are used for fungal infections of the eye, which are rare and usually occur after trauma or surgery. The client may need antibiotic or antiviral drops, depending on the cause of conjunctivitis.

Choice C Reason: This is an incorrect choice. Scheduling a sexually transmitted infection (STI/STD) exam is not a home care instruction that the nurse will offer to the client, as it is not relevant for conjunctivitis. STIs can affect the eyes, but they usually cause different symptoms, such as redness, pain, or discharge from the urethra or vagina. The client may need to be tested for STIs if they have other risk factors or signs of infection.

Choice D Reason: This is an incorrect choice. Avoiding going outside during daylight hours is not a home care instruction that the nurse will offer to the client, as it is not necessary for conjunctivitis. The client may experience sensitivity to light, but they can wear sunglasses or avoid direct sunlight to protect their eyes. The client should also avoid rubbing or touching their eyes, wear glasses instead of contact lenses, and discard any eye makeup or cosmetics that may be contaminated.

A. Education about mastoidectomy B. A referral for a hearing test C. Education on administration of oral antibiotics D. A prescription for an antifungal cream

Correct Answer is C

Explanation

Choice A reason: This is incorrect because education about mastoidectomy is not relevant for a client with an upper respiratory infection. Mastoidectomy is a surgical procedure that removes part or all of the mastoid bone behind the ear, which can become infected or inflamed due to chronic or recurrent middle ear infections. The nurse should assess the client's ear for signs of mastoiditis, such as swelling, tenderness, or redness behind the ear, but mastoidectomy is not a common or first-line treatment for upper respiratory infection.
Choice B reason: This is incorrect because a referral for a hearing test is not necessary for a client with an upper respiratory infection. Hearing test is a diagnostic tool that measures how well a person can hear different sounds at different frequencies and intensities. The nurse should ask the client about any changes in hearing or tinnitus, which are possible complications of upper respiratory infection, but a hearing test is not a routine or urgent intervention for this condition.
Choice C reason: This is correct because education on the administration of oral antibiotics can help treat an upper respiratory infection. Antibiotics are drugs that kill or inhibit bacteria that cause infections. Upper respiratory infections can be caused by various pathogens, such as viruses, bacteria, or fungi, but bacterial infections are more likely to cause fever, otalgia, or purulent nasal drainage. The nurse should instruct the client on how to take antibiotics as prescribed, such as dosage, frequency, duration, side effects, and interactions.
Choice D reason: This is incorrect because a prescription for an antifungal cream is not appropriate for a client

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