# A 38-year-old male client is admitted to the medical-surgical unit with acute cholecystitis. He reports severe right upper quadrant pain that radiates to his right shoulder, nausea, and vomiting. His vital signs are: temperature 102.0°F (38.9°C), pulse 115 bpm, respirations 26/min, and blood pressure 130/85 mmHg. Laboratory results show elevated white blood cell count and liver enzymes. The client appears restless and is guarding his abdomen. A nurse is caring for this client. Which nursing intervention should be the priority?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=540541  
> language: ko  
> subject: Adult Health

## 문제

A 38-year-old male client is admitted to the medical-surgical unit with acute cholecystitis. He reports severe right upper quadrant pain that radiates to his right shoulder, nausea, and vomiting. His vital signs are: temperature 102.0°F (38.9°C), pulse 115 bpm, respirations 26/min, and blood pressure 130/85 mmHg. Laboratory results show elevated white blood cell count and liver enzymes. The client appears restless and is guarding his abdomen. A nurse is caring for this client. Which nursing intervention should be the priority?

## 보기

1. Administer prescribed analgesics for pain relief
2. Maintain the client on NPO (nothing by mouth) status **✔ 정답**
3. Apply heat to the right upper quadrant
4. Encourage early ambulation to prevent complications

**정답: 2**

## 해설

Maintaining NPO status is the priority to prevent gallbladder stimulation and reduce inflammation in acute cholecystitis. Analgesics, heat application, or ambulation are secondary to this initial management.

## 심화 해설

Understanding Acute Cholecystitis and the Priority Nursing Intervention

For a client presenting with acute cholecystitis, the priority nursing intervention is to maintain NPO (nothing by mouth) status. This decision is rooted in the pathophysiology of the condition and the immediate risks to the client, which directly informs the clinical reasoning required for the NCLEX-RN.

Pathophysiology and Clinical Correlation

The client’s symptoms—severe right upper quadrant pain radiating to the shoulder, fever of 102.0°F (38.9°C), tachycardia at 115 bpm, tachypnea, and abdominal guarding—indicate an active inflammatory and infectious process within the gallbladder. The gallbladder is stimulated to contract and release bile in response to food intake, particularly fatty meals. In acute cholecystitis, this contraction against an obstructed cystic duct (typically by a gallstone) causes intense pain and can worsen inflammation. More critically, the client is at high risk for clinical deterioration requiring an urgent surgical or interventional procedure. The elevated white blood cell count and liver enzymes signal systemic involvement and potential common bile duct obstruction.

Rationale for Priority: NPO Status

The foundational principle in managing a client with an acute abdomen is to rest the gastrointestinal tract. Placing the client on NPO status achieves several critical goals simultaneously:

- Prevents Gallbladder Stimulation: Oral intake triggers the release of cholecystokinin, which causes gallbladder contraction. Keeping the client NPO minimizes this stimulation, helping to reduce pain and prevent exacerbation of the inflammatory process.

- Prepares for Potential Procedures: The client’s unstable presentation necessitates preparation for possible emergency surgery, such as a laparoscopic cholecystectomy, or an interventional drainage procedure. The WSES position paper highlights the importance of a multimodal, interdisciplinary approach in emergency general surgery to improve perioperative recovery [1]. An immediate component of this preparation is ensuring the stomach is empty to reduce the risk of pulmonary aspiration during anesthesia or sedation. This aligns with enhanced perioperative care protocols designed to reduce surgical stress and improve outcomes [1].

- Manages Nausea and Vomiting: The client is actively nauseous and vomiting. Maintaining NPO status is a direct intervention to manage these symptoms and prevent further fluid and electrolyte loss.

Analysis of Other Options

While the other interventions are relevant to the client’s care, they are not the immediate priority.

- Administering prescribed analgesics is essential for pain management, but it is not the first action. The nurse must first ensure the client’s safety by placing them on NPO status. Administering oral analgesics would violate the NPO order, and even parenteral analgesia is secondary to the critical step of preparing the client for a potentially emergent clinical course.

- Applying heat to the right upper quadrant is contraindicated. Heat application can increase blood flow and potentially worsen inflammation and edema in an acutely inflamed organ. It may also mask the progression of symptoms, delaying necessary interventions.

- Encouraging early ambulation is a key component of enhanced recovery after surgery (ERAS) protocols, which have been shown to improve gastrointestinal recovery and quality of life in patients undergoing laparoscopic cholecystectomy [2,3]. However, this intervention is appropriate for the postoperative phase. In the acute preoperative phase, the client is hemodynamically unstable, in severe pain, and requires immediate stabilization and preparation for a procedure, making ambulation an unsafe and non-priority action.

Connecting to Perioperative Care Principles

The priority of NPO status directly supports the broader framework of perioperative care in emergency general surgery. The goal is to initiate a care pathway that reduces surgical stress and optimizes the client’s condition from the moment of admission. For a high-risk surgical patient with acute cholecystitis, the initial steps of resuscitation and preparation, including establishing NPO status, are paramount before any definitive treatment, whether it is a laparoscopic cholecystectomy or an alternative procedure like endoscopic ultrasound-guided gallbladder drainage for frail patients [1,4]. The nurse’s immediate action of placing the client on NPO status is the critical first link in this chain of safe and effective perioperative care.References (research sources)

- [1]Enhanced perioperative care in emergency general surgery: the WSES position paper.Research articleCeresoli M, Braga M, Zanini N, Abu-Zidan FM, Parini D, Langer T, Sartelli M, Damaskos D, Biffl WL, Amico F, Ansaloni L, Balogh ZJ, Bonavina L, Civil I, Cicuttin E, Chirica M, Cui Y, De Simone B, Di Carlo I, Fette A, Foti G, Fogliata M, Fraga GP, Fugazzola P, Galante JM, Beka SG, Hecker A, Jeekel J, Kirkpatrick AW, Koike K, Leppäniemi A, Marzi I, Moore EE, Picetti E, Pikoulis E, Pisano M, Podda M, Sakakushev BE, Shelat VG, Tan E, Tebala GD, Velmahos G, Weber DG, Agnoletti V, Kluger Y, Baiocchi G, Catena F, Coccolini F. (2023) · DOI: 10.1186/s13017-023-00519-2

## 임상 시나리오

Acute Cholecystitis: NPO PriorityImmediate nursing action for the inflamed gallbladder
The priority intervention is to maintain NPO status. Oral intake triggers cholecystokinin release, causing gallbladder contraction against an obstructed cystic duct, which worsens pain and inflammation.

NPO status rests the gastrointestinal tract, prevents further gallbladder stimulation, and prepares the client for potential emergency surgery or endoscopic intervention. It is a critical safety measure for the acute abdomen.

CautionDo not apply heat to the right upper quadrant; this can increase inflammation and risk of perforation. Pain management is secondary to stabilizing the client and preventing complications from oral intake.

## 핵심 개념

- **Acute Cholecystitis** — Inflammation of the gallbladder often caused by gallstone obstruction of the cystic duct, leading to bile stasis, chemical irritation, and infection.
- **NPO (Nothing by Mouth)** — A medical order instructing the patient to refrain from oral intake of food and fluids, used to rest the gastrointestinal tract and prevent gallbladder stimulation.
- **Biliary Stasis** — The slowing or cessation of bile flow, a key pathophysiological factor in cholecystitis that promotes inflammation and stone formation.
- **Phrenic Nerve Irritation** — Irritation of the nerve supplying the diaphragm, which can cause referred pain to the right shoulder tip, a classic sign in acute cholecystitis.
- **Guarding** — Involuntary tensing of the abdominal muscles during palpation, indicating peritoneal irritation and a surgical abdomen.

## 같은 주제 문제

- [A 47-year-old female patient presents to the emergency department with severe right upper …](https://mymerci.kr/pages/nclex_q.php?qn_id=540539)
- [A nurse is assessing a 28-year-old pregnant client who presents to the emergency departmen…](https://mymerci.kr/pages/nclex_q.php?qn_id=540540)
- [A nurse is caring for a client with acute cholecystitis who is scheduled for laparoscopic …](https://mymerci.kr/pages/nclex_q.php?qn_id=540542)
- [A nurse is caring for a patient with acute cholecystitis who is scheduled for laparoscopic…](https://mymerci.kr/pages/nclex_q.php?qn_id=540543)
- [A nurse is caring for a client with acute cholecystitis. Which assessment finding requires…](https://mymerci.kr/pages/nclex_q.php?qn_id=540544)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._