which of the following factors should be the main focus of nursing management for a client hospitalized for cholecystitis
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Nursing Elites

ATI RN

ATI Gastrointestinal System

1. Which of the following factors should be the main focus of nursing management for a client hospitalized for cholecystitis?

Correct answer: B

Rationale: Assessment for complications should be the main focus of nursing management for a client hospitalized for cholecystitis.

2. You have a patient with achalasia (incomplete muscle relaxation of the GI tract, especially sphincter muscles). Which medications do you anticipate to administer?

Correct answer: A

Rationale: Isosorbide dinitrate (Isordil) is a medication used to relax the muscles of the GI tract in patients with achalasia.

3. Which nursing measure would be most effective in helping the client cough and deep breathe after a cholecystectomy?

Correct answer: C

Rationale: After a cholecystectomy, teaching the client to use a folded blanket or pillow to splint the incision will be most effective in helping the client cough and deep breathe. This technique provides support and reduces pain during coughing and deep breathing, promoting better lung expansion. Having the client take rapid, shallow breaths would not be effective in decreasing pain; instead, deep breathing is encouraged to prevent complications like atelectasis. Lying on the left side would limit lung expansion; therefore, the client should be positioned in semi-Fowler's or Fowler's position to maximize lung expansion. Withholding pain medication can lead to discomfort and reluctance to cough and deep breathe, hindering recovery.

4. A client with liver dysfunction has low serum levels of thrombin. The nurse provides care, anticipating that this client is most at risk of

Correct answer: C

Rationale: Thrombin is produced by the liver and is necessary for normal clotting. When a client with liver dysfunction has low serum levels of thrombin, they are at risk of bleeding due to impaired clotting mechanisms. Dehydration (choice A) is not directly related to low thrombin levels. Malnutrition (choice B) may impact overall health but is not the most immediate concern associated with low thrombin levels. Infection (choice D) is not directly related to the clotting function affected by low thrombin levels.

5. If a gastric acid perforates, which of the following actions should not be included in the immediate management of the client?

Correct answer: B

Rationale: Antacid administration should not be included in the immediate management of a gastric perforation.

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