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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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 of the following treatments is used for rectal cancer but not for colon cancer?

Correct answer: C

Rationale: Radiation therapy is commonly used for rectal cancer to shrink the tumor before surgery, which is not typically done for colon cancer.

3. In a client with diarrhea, which outcome indicates that fluid resuscitation is successful?

Correct answer: C

Rationale: Firm skin turgor indicates adequate hydration, which is a key goal of fluid resuscitation. Formed stools, decreased stool frequency, and relief from perianal burning are important but do not directly indicate successful fluid resuscitation.

4. The client is admitted to the hospital with viral hepatitis, complaining of 'no appetite' and 'losing my taste for food.' To provide adequate nutrition, the nurse would instruct the client to

Correct answer: C

Rationale: Although no special diet is required to treat viral hepatitis, it is generally recommended that clients consume a diet with low-fat content because fat may be tolerated poorly due to decreased bile production. Small, frequent meals are preferable and may prevent nausea. Appetite is often better in the morning, so it is easier to eat a good breakfast. An adequate fluid intake of 2500 to 3000 mL per day that includes nutritional juices is also important.

5. Cholestyramine resin (Questran Light) is prescribed for the client with an elevated serum cholesterol level. The nurse would instruct the client to take the medication

Correct answer: B

Rationale: Cholestyramine resin binds with bile salts in the intestines to form a compound that is excreted in the feces. The client should be instructed to mix the medication with 3 to 6 oz of water, milk, fruit juice, or soup. The medication should be administered before meals. The medication is not administered via rectal suppository.

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