Gastrointestinal System Nursing Exam Questions

Correct Answer: C

Rationale: Hematocrit is the best indicator of hydration status because it reflects the proportion of red blood cells in the blood. An increased hematocrit indicates dehydration, as the blood becomes more concentrated due to fluid loss. Erythrocyte sedimentation rate (Choice A) is a nonspecific marker of inflammation, not hydration status. White blood cell count (Choice B) is an indicator of infection or inflammation. Serum glucose (Choice D) is used to monitor blood sugar levels, not hydration status.

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.

Correct Answer: A

Rationale: The abdominal cramping that can occur during colostomy irrigation results from stimulation of the colon by the irrigating solution. The nurse's first response should be to temporarily stop the flow of solution to allow the cramping to subside. Repositioning the client to the right side will not alleviate the cramping. Removing the tube will not decrease the cramping and will necessitate reinsertion of the tube when the irrigation is resumed. Massaging the abdomen gently may be soothing to some clients, but it is not the nurse's first priority action.

Correct Answer: C

Rationale: Laboratory indicators of hepatitis include elevated liver enzymes, serum bilirubin level, and erythrocyte sedimentation rate is nonspecific test that indicates the presence of inflammation somewhere in the body. Elevated blood urea nitrogen may indicate renal dysfunction. A hemoglobin level is unrelated to this diagnosis.

Correct Answer: D

Rationale: A client who experiences dumping syndrome after a subtotal gastrectomy should be advised to ingest liquids between meals rather than with meals. Taking fluids between meals allows for adequate hydration, reduces the amount of bulk ingested with meals, and aids in preventing rapid gastric emptying. There is no need to restrict the amount of fluids, just the time when the client drinks fluids. Drinking liquids with meals increases the risk of dumping syndrome by increasing the amount of bulk and stimulating rapid gastric emptying. Small amounts of water are allowable before meals.