A nurse is caring for a client who had a cholecystostomy for cholecystitis. The client reports pain at the site of the drainage tube. Upon assessment, the nurse notes redness and swelling around the insertion site. Which of the following actions should the nurse take first?
Administer a pain medication to relieve the client's discomfort.
Notify the healthcare provider about the client's symptoms and findings.
Apply an ice pack to the insertion site to reduce inflammation.
Change the dressing and clean the insertion site with an antiseptic solution.
The Correct Answer is B
Choice A reason:
While pain relief is important, it is essential to address the redness and swelling first, as they may indicate an infection or other complication related to the cholecystostomy.
Choice B reason:
This statement is correct. The nurse should notify the healthcare provider immediately about the client's symptoms and findings to ensure prompt evaluation and appropriate interventions.
Choice C reason:
Applying an ice pack may provide some relief for pain and inflammation, but it does not address the potential underlying cause of redness and swelling.
Choice D reason:
Changing the dressing and cleaning the insertion site is important for maintaining cleanliness, but the nurse should first notify the healthcare provider about the client's symptoms for further evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Administering pain medication is important, but assessing the client's vital signs and pain level takes priority to determine the severity of the pain and the appropriate intervention.
Choice B reason:
This statement is correct. Assessing the client's vital signs and pain level is the first action the nurse should take to evaluate the client's condition and determine the appropriate intervention.
Choice C reason:
Placing the client in a semi-Fowler's position may provide some comfort, but it does not address the underlying pain or assist in determining the severity of the situation.
Choice D reason:
Offering herbal tea for relaxation is a non-pharmacological intervention that can be helpful, but it is not the first action the nurse should take when the client is experiencing severe abdominal pain.
Correct Answer is C
Explanation
Choice A reason:
Diabetes does not increase bile production. However, it can lead to changes in bile composition, increasing the risk of gallstone formation.
Choice B reason:
This statement is incorrect. Diabetes is associated with increased cholesterol levels in the bile, which can contribute to gallstone formation.
Choice C reason:
This statement is correct. Diabetes can impair the function of the sphincter of Oddi, a muscular valve that controls the flow of bile into the duodenum. Dysfunction of the sphincter can lead to bile stasis and increase the risk of gallstone formation.
Choice D reason:
Diabetes does not increase the motility of the gallbladder. Instead, it may lead to reduced gallbladder motility, which can contribute to gallstone formation due to stasis of bile.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.