Biliary Tract Problems
Answer: Oral temperature of 101.8° F
Rationale: An oral temperature of 101. 8º F on the third postoperative day indicates a possible
infection and requires further evaluation and modification of the nursing plan of care. Tolerating
a full liquid diet and pain at level of 5 on a 0 to 10 scale are appropriate outcomes at this time.
Although fluid intake is low, it is in balance with the output; therefore it would not be as high a
priority as the increased temperature.
Text Reference - p. 1040 - ANS-The nurse is providing postoperative care to a patient who
underwent open cholecystectomy 3 days ago. Which finding during the nurse's assessment
should prompt the nurse to notify the primary health care provider?
A. Tolerance of a full-liquid diet
B. Oral temperature of 101.8° F
C. Report of pain at a level 5 on a scale of 0 to 10
D. An 8-hour fluid intake of 680 mL and an output of 660 mL
Answer: A lower-fat diet may be tolerated better for several weeks
Rationale: Although the usual diet can be resumed, a low-fat diet usually is better tolerated for
several weeks following surgery. Normal activities can be resumed gradually as the patient
tolerates. Bile-colored drainage or pus, redness, swelling, severe pain, and fever may all
indicate infection. The bandage may be removed the day after surgery and the patient can
shower. - ANS-When providing discharge teaching for the patient after a laparoscopic
cholecystectomy, what information should the nurse include?
A. A lower-fat diet may be tolerated better for several weeks
B. Do not return to work or normal activities for three weeks
C. Bile-colored drainage probably will drain from the incision
D. Keep the bandages on and the puncture site dry until it heals
Answer: Right upper quadrant pain radiating to the patient's back
Rationale: The pain of cholecystitis is in the region of the gallbladder (right upper quadrant),
which is inflamed as a result of infection and irritation from bile. The pain may be referred to the
right shoulder and scapula. Left flank pain with intermittent exacerbations may be caused by
renal calculi. Right lower quadrant pain with rebound tenderness may be related to acute
appendicitis, Crohn's disease, or peritonitis. Epigastric pain that intensifies when the patient is
lying down may be related to gastroesophageal reflux disease or hiatal hernia.
Text Reference - p. 1037 - ANS-Which clinical manifestation of pain does the nurse expect to
identify in a patient who has cholecystitis?
A. Left flank pain with intermittent exacerbations
B. Right lower quadrant pain with rebound tenderness
C. Right upper quadrant pain radiating to the patient's back
D. Epigastric pain that intensifies when the patient is lying down
Answer: Oral temperature of 101.8° F
Rationale: An oral temperature of 101. 8º F on the third postoperative day indicates a possible
infection and requires further evaluation and modification of the nursing plan of care. Tolerating
a full liquid diet and pain at level of 5 on a 0 to 10 scale are appropriate outcomes at this time.
Although fluid intake is low, it is in balance with the output; therefore it would not be as high a
priority as the increased temperature.
Text Reference - p. 1040 - ANS-The nurse is providing postoperative care to a patient who
underwent open cholecystectomy 3 days ago. Which finding during the nurse's assessment
should prompt the nurse to notify the primary health care provider?
A. Tolerance of a full-liquid diet
B. Oral temperature of 101.8° F
C. Report of pain at a level 5 on a scale of 0 to 10
D. An 8-hour fluid intake of 680 mL and an output of 660 mL
Answer: A lower-fat diet may be tolerated better for several weeks
Rationale: Although the usual diet can be resumed, a low-fat diet usually is better tolerated for
several weeks following surgery. Normal activities can be resumed gradually as the patient
tolerates. Bile-colored drainage or pus, redness, swelling, severe pain, and fever may all
indicate infection. The bandage may be removed the day after surgery and the patient can
shower. - ANS-When providing discharge teaching for the patient after a laparoscopic
cholecystectomy, what information should the nurse include?
A. A lower-fat diet may be tolerated better for several weeks
B. Do not return to work or normal activities for three weeks
C. Bile-colored drainage probably will drain from the incision
D. Keep the bandages on and the puncture site dry until it heals
Answer: Right upper quadrant pain radiating to the patient's back
Rationale: The pain of cholecystitis is in the region of the gallbladder (right upper quadrant),
which is inflamed as a result of infection and irritation from bile. The pain may be referred to the
right shoulder and scapula. Left flank pain with intermittent exacerbations may be caused by
renal calculi. Right lower quadrant pain with rebound tenderness may be related to acute
appendicitis, Crohn's disease, or peritonitis. Epigastric pain that intensifies when the patient is
lying down may be related to gastroesophageal reflux disease or hiatal hernia.
Text Reference - p. 1037 - ANS-Which clinical manifestation of pain does the nurse expect to
identify in a patient who has cholecystitis?
A. Left flank pain with intermittent exacerbations
B. Right lower quadrant pain with rebound tenderness
C. Right upper quadrant pain radiating to the patient's back
D. Epigastric pain that intensifies when the patient is lying down
