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.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is B
Explanation
Choice A reason:
Rebound tenderness in the right upper quadrant is not a hallmark sign of acute cholecystitis. It may be present in conditions such as appendicitis or peritonitis.
Choice B reason:
This statement is correct. Murphy's sign is a hallmark sign of acute cholecystitis. It is elicited by asking the client to take a deep breath while the nurse palpates the right upper quadrant. If the client abruptly stops breathing due to pain upon palpation, it indicates inflammation of the gallbladder (positive Murphy's sign).
Choice C reason:
Hypoactive bowel sounds may be present in some gastrointestinal conditions but are not specific to acute cholecystitis.
Choice D reason:
Left lower quadrant abdominal pain is not associated with acute cholecystitis. This type of pain is more commonly seen in conditions such as diverticulitis or colitis.
Correct Answer is B
Explanation
Choice A reason:
While chronic cholecystitis can lead to complications, such as gallbladder inflammation and gallstones, it is not a typical cause of gallbladder cancer.
Choice B reason:
This statement is correct. Complications of chronic cholecystitis may include pancreatitis, which is inflammation of the pancreas, and cholangitis, which is inflammation of the bile ducts. These complications can occur if gallstones migrate from the gallbladder and obstruct the pancreatic or bile ducts.
Choice C reason:
This statement is incorrect. Chronic cholecystitis is inflammation of the gallbladder, not the pancreas. However, complications of chronic cholecystitis, such as gallstone migration, can cause acute inflammation of the pancreas (pancreatitis).
Choice D reason:
Complications of chronic cholecystitis do not typically include lung infections. The primary complications are related to the gallbladder, pancreas, and bile ducts.
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