which of the following nursing interventions should have the highest priority during the first hour after the admission of a client with cholecystitis 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. Which parameter correlates best with measurements of total muscle mass?

Correct answer: D

Rationale: Upper arm circumference correlates best with total muscle mass because it includes both muscle and fat components, making it a reliable indicator of muscle mass.

3. How should a healthcare professional assess a patient's pain who is non-verbal?

Correct answer: A

Rationale: When assessing pain in non-verbal patients, looking for changes in vital signs that may indicate pain is crucial. While using alternative methods like touch or distraction can be helpful, they may not directly indicate the presence of pain. Using a pain scale appropriate for non-verbal patients is important, but it may not always provide immediate feedback. Observing for facial expressions or other non-verbal cues can be subjective and may not always accurately reflect the level of pain the patient is experiencing. Therefore, monitoring vital signs is a more objective way to assess pain in non-verbal patients.

4. A client with chronic obstructive pulmonary disease (COPD) appears thin and disheveled. Which question should the nurse ask first?

Correct answer: C

Rationale: In clients with severe COPD, shortness of breath can significantly impact their ability to perform basic activities like bathing and eating. Therefore, the nurse's priority should be to assess if shortness of breath is interfering with the client's basic activities, which can provide crucial information for planning and managing care.

5. Which of the following is a common effect of persistent discrimination?

Correct answer: C

Rationale: The correct answer is C: Cardiovascular reactivity. Persistent discrimination can have negative impacts on an individual's physical health, leading to increased cardiovascular reactivity. This can manifest as higher blood pressure, heart rate, and overall stress on the cardiovascular system. Choices A, B, and D are incorrect because persistent discrimination typically does not result in increased happiness, greater intelligence and wisdom, or increased consciousness. Instead, it often leads to detrimental effects on mental and physical health.

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