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. Leigh Ann is receiving pancrelipase (Viokase) for chronic pancreatitis. Which observation best indicates the treatment is effective?

Correct answer: D

Rationale: The effectiveness of pancrelipase (Viokase) for chronic pancreatitis is best indicated by stools being less fatty and decreased in frequency.

3. You’re preparing a patient with a malignant tumor for colorectal surgery and subsequent colostomy. The patient tells you he’s anxious. What should your initial step be in working with this patient?

Correct answer: A

Rationale: When a patient with a malignant tumor is anxious about colorectal surgery and a colostomy, the initial step is to determine what the patient already knows about colostomies.

4. The client with Crohn’s disease has a nursing diagnosis of acute pain. The nurse would teach the client to avoid which of the following in managing this problem?

Correct answer: A

Rationale: Lying supine with the legs straight can increase abdominal tension and exacerbate pain. The client should be advised to lie with the legs bent to reduce muscle tension and discomfort.

5. A client with viral hepatitis states, 'I am so yellow.' The nurse most appropriately would

Correct answer: A

Rationale: To assist the client in adapting to changes in appearance, the nurse must encourage participation in self-care to foster independence and self-esteem. The nurse should encourage the client to ask questions to clarify misconceptions, learn ways to prevent the spread of hepatitis to reduce fear, and make appropriate decisions. Restricting visitors will reinforce the client’s negative self-esteem.

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