Today’s NCLEX-RN® question of the day focuses on a client with acute cholecystitis. Can you figure it out?
The nurse is caring for a client admitted to the surgical unit for acute cholecystitis. What action should the nurse prioritize?
A. Implement NPO status
B. Ask the client to rate their pain level
C. Ensure the client is on bedrest
D. Administer the prescribed analgesics
Scroll down for the correct answer!
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The correct answer to today’s NCLEX-RN® Question is…
B. Ask the client to rate their pain level
Rationale: The nurse should evaluate the client’s pain, including the onset, quality, severity, location, aggravating or relieving factors, and how frequently they experience pain. Severe pain may be related to complications such as infection, ischemia, perforation, and peritonitis, all of which can cause significant harm or death to the client.
Main takeaway
The nurse’s priority goals when caring for a client with cholecystitis is to monitor for complications, which include gallbladder infection, ischemia, gangrenous tissue death, perforation, peritonitis, sepsis, and provide supportive care to relieve symptoms like fever, nausea, vomiting, and pain. The nurse should begin by asking clients about their pain, including the onset, quality, severity, location, aggravating or relieving factors, and how frequently they experience pain. Next, the nurse should assist them to become comfortable and administer the prescribed analgesics. In addition, if clients have itching from jaundice, the nurse should administer antihistamines. As prescribed, the nurse should institute NPO status for nausea and vomiting, administer intravenous fluids and antiemetics, and insert a nasogastric tube for gastric decompression.
Incorrect answer explanations
A. Implement NPO status
Rationale: Although NPO, or nothing by mouth, status is implemented for clients diagnosed with acute cholecystitis for various reasons, it is not the priority intervention.
C. Ensure the client is on bedrest
Rationale: A client with acute cholecystitis does not necessarily have to be on bedrest. There is another more appropriate action that the nurse should prioritize.
D. Administer the prescribed analgesics
Rationale: Although the nurse should plan to administer prescribed analgesics if the client is in pain, it should occur after another nursing intervention.
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