which of the following nursing interventions should have the highest priority during the first hour after the admission of a client with cholecystitis
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Nursing Elites

ATI RN

Gastrointestinal System Nursing Exam Questions

1. Which of the following nursing interventions should have the highest priority during the first hour after the admission of a client with cholecystitis who is experiencing pain, nausea, and vomiting?

Correct answer: A

Rationale: Administering pain medication would have the highest priority during the first hour after the client's admission. Pain relief is essential to address the client's immediate discomfort and distress. Completing the admission history, maintaining hydration, and teaching about planned diagnostic tests are important aspects of care but can be addressed after addressing the client's pain and stabilizing their condition.

2. A nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis. The client is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment the nurse notes that the abdomen is distended and the bowel sounds are diminished. Which of the following is the most appropriate nursing intervention?

Correct answer: B

Rationale: The symptoms suggest possible perforation or peritonitis, which are serious complications requiring immediate medical attention. The nurse should promptly notify the physician.

3. Which of the following tests can be performed to diagnose a hiatal hernia?

Correct answer: C

Rationale: A barium swallow is a diagnostic test that can visualize the esophagus, stomach, and small intestine to diagnose a hiatal hernia.

4. After a right hemicolectomy for treatment of colon cancer, a 57-year old client is reluctant to turn while on bed rest. Which action by the nurse would be appropriate?

Correct answer: B

Rationale: Educating the client about the importance of turning can encourage compliance and promote understanding of the necessity to prevent complications such as pressure ulcers and pneumonia.

5. A client with peptic ulcer is scheduled for a Vagotomy. The client asks the nurse about the purpose of this procedure. The nurse tells the client that the procedure

Correct answer: D

Rationale: A vagotomy, or cutting of the vagus nerve, is done to eliminate parasympathetic stimulation of gastric secretion, thereby reducing the stimulus to acid secretions. Options A, B, and C are incorrect as a vagotomy does not affect food absorption, heal the gastric mucosa, or halt stress reactions.

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