Lower GI -Lippincotts
When planning care for a client with ulcerative colitis who is experiencing an exacerbation of symptoms, which client care activities can the nurse appropriately delegate to an unlicensed assistant? Select all that apply. 1. Assessing the client's bowel sounds. 2. Providing skin care following bowel movements. 3. Evaluating the client's response to antidiarrheal medications. 4. Maintaining intake and output records. 5. Obtaining the client's weight.
2, 4, 5. The nurse can delegate the following basic care activities to the unlicensed assistant: providing skin care following bowel movements, maintaining intake and output records, and obtaining the client's weight. Assessing the client's bowel sounds and evaluating the client's response to medication are registered nurse activities that cannot be delegated.
Which of the following statements about nasoenteric tubes is correct? 1. The tube cannot be attached to suction. 2. The tube contains a soft rubber bag filled with mercury. 3. The tube is taped securely to the client's cheek after insertion. 4. The tube can have its placement determined only by auscultation.
2. A nasoenteric tube has a small balloon at its tip that is weighted with mercury. The weight of the mercury helps advance the tube by gravity through the intestine. Nasoenteric tubes are attached to suction. A nasoenteric tube is not taped in position until it has reached the obstruction. Because the tube has a radiopaque strip, its progress through the intestinal tract can be followed by fluoroscopy.
The client with ulcerative colitis is following orders for bed rest with bathroom privileges. When evaluating the effectiveness of this level of activity, the nurse should determine if the client has: 1. Conserved energy. 2. Reduced intestinal peristalsis. 3. Obtained needed rest. 4. Minimized stress.
2. Although modified bed rest does help conserve energy and promotes comfort, its primary purpose in this case is to help reduce the hypermotility of the colon. Remaining on bed rest does not by itself reduce stress, and if the client is having stress, the nurse can plan with the client to use strategies that will help the client manage the stress.
A client who had an appendectomy for a perforated appendix returns from surgery with a drain inserted in the incisional site. The purpose of the drain is to: 1. Provide access for wound irrigation. 2. Promote drainage of wound exudates. 3. Minimize development of scar tissue. 4. Decrease postoperative discomfort.
2. Drains are inserted postoperatively in appendectomies when an abscess was present or the appendix was perforated. The purpose is to promote drainage of exudate from the wound and facilitate healing. A drain is not used for irrigation of the wound. The drain will not minimize scar tissue development or decrease postoperative discomfort.
The client with an intestinal obstruction continues to have acute pain even though the nasoenteric tube is patent and draining. Which action by the nurse would be most appropriate? 1. Reassure the client that the nasoenteric tube is functioning. 2. Assess the client for a rigid abdomen. 3. Administer an opioid as ordered. 4. Reposition the client on the left side.
2. The client's pain may be indicative of peritonitis, and the nurse should assess for signs and symptoms, such as a rigid abdomen, elevated temperature, and increasing pain. Reassuring the client is important, but accurate assessment of the client is essential. The full assessment should occur before pain relief measures are employed. Repositioning the client to the left side will not resolve the pain.
Which of the following adverse effects would the nurse expect the client to exhibit in the event of too rapid an infusion of TPN solution? 1. Negative nitrogen balance. 2. Circulatory overload. 3. Hypoglycemia. 4. Hypokalemia.
2. Too rapid infusion of a TPN solution can lead to circulatory overload. The client should be assessed carefully for indications of excessive fluid volume. A negative nitrogen balance occurs in nutritionally depleted individuals, not when TPN fluids are administered in excess. When TPN is administered too rapidly the client is at risk for receiving an excess of dextrose and electrolytes. Therefore, the client is at risk for hyperglycemia and hyperkalemia.
While changing the client's colostomy bag and dressing, the nurse assesses that the client is ready to participate in her care by noting which of the following? 1. The client asks what time the doctor will visit that day. 2. The client asks about the supplies used during the dressing change. 3. The client talks about something she read in the morning newspaper. 4. The client complains about the way the night nurse changed the dressing.
2. A client who displays interest in the procedure and asks about supplies used for dressings may be ready to participate in self-care. Inquiring about the physician's visit, discussing news events, and complaining about a dressing change are behaviors that avoid the subject of the colostomy.
HEMORRHOIDS A 36-year-old female client has been diagnosed with hemorrhoids. Which of the following factors in the client's history would most likely be a primary cause of her hemorrhoids? 1. Her age. 2. Three vaginal delivery pregnancies. 3. Her job as a schoolteacher. 4. Varicosities in her legs.
2. Hemorrhoids are associated with prolonged sitting or standing, portal hypertension, chronic constipation, and prolonged increased intra-abdominal pressure, as associated with pregnancy and the strain of vaginal delivery. Her job as a schoolteacher does not require prolonged sitting or standing. Age and leg varicosities are not related to the development of hemorrhoids.
The nurse evaluates the client's understanding of ileostomy care. Which of the following statements indicates that discharge teaching has been effective? 1. "I should be able to resume weight lifting in 2 weeks." 2. "I can return to work in 2 weeks." 3. "I need to drink at least 3,000 mL a day of fluid." 4. "I will need to avoid getting my stoma wet while bathing."
3. To maintain an adequate fluid balance, the client needs to drink at least 3,000 mL/ day. Heavy lifting should be avoided; the physician will indicate when the client can participate in sports again. The client will not resume working as soon as 2 weeks after surgery. Water does not harm the stoma, so the client does not have to worry about getting it wet.
A client who is experiencing an exacerbation of ulcerative colitis is receiving I.V. fluids that are to be infused at 125 mL/ hour. The I.V. tubing delivers 15 gtt/ mL. How quickly should the nurse infuse the fluids in drops per minute to infuse the fluids at the prescribed rate? ________________________ gtt/ minute.
31 gtt/ minute To administer I.V. fluids at 125 mL/ hour using tubing that has a drip factor of 15 gtt/ mL, the nurse should use the following formula: 125 mL/ 60 minutes × 15 gtt/ 1 mL = 31 gtt/ minute.
A client is receiving Total Parenteral Nutrition (TPN) soulution. The nurse should assess a client's ability to metabolize the TPN solution adequately by monitoring the client for which of the following signs? 1. Tachycardia. 2. Hypertension. 3. Elevated blood urea nitrogen concentration. 4. Hyperglycemia.
4. During TPN administration, the client should be monitored regularly for hyperglycemia. The client may require small amounts of insulin to improve glucose metabolism. The client should also be observed for signs and symptoms of hypoglycemia, which may occur if the body overproduces insulin in response to a high glucose intake or if too much insulin is administered to help improve glucose metabolism. Tachycardia or hypertension is not indicative of the client's ability to metabolize the solution. An elevated blood urea nitrogen concentration is indicative of renal status and fluid balance.
A client with a well-managed ilesostomy calls the nurse to report the sudden onset of abdominal cramps, vomiting, and watery discharge from the ileostomy. The nurse should: 1. Tell the client to take an antiemetic. 2. Encourage the client to increase fluid intake to 3 L/ day to replace fluid lost through vomiting. 3. Instruct the client to take 30 mL of milk of magnesia to stimulate a bowel movement. 4. Advise the client to notify the physcian.
4. Sudden onset of abdominal cramps, vomiting, and watery discharge with no stool from an ileostomy are likely indications of an obstruction. It is imperative that the physician examine the client immediately. Although the client is vomiting, the client should not take an antiemetic until the physician has examined the client. If an obstruction is present, ingesting fluids or taking milk of magnesia will increase the severity of symptoms. Oral intake is avoided when a bowel obstruction is suspected.
Which of the following has been identified as a potential risk factor for the development of colon cancer? 1. Chronic constipation. 2. Long-term use of laxatives. 3. History of smoking. 4. History of inflammatory bowel disease.
4. A history of inflammatory bowel disease is a risk factor for colon cancer. Other risk factors include age (older than 40 years), history of familial polypo-sis, colorectal polyps, and high-fat or low-fiber diet.
After an inguinal herniorrhaphy, the nurse should assess the client carefully for which of the following likely complications? 1. Hypostatic pneumonia. 2. Deep vein thrombosis. 3. Paralytic ileus. 4. Urine retention.
4. The most common complication after an inguinal hernia repair is the inability to void, especially in men. The nurse should evaluate the client carefully for urine retention. Hypostatic pneumonia, deep vein thrombosis, and paralytic ileus are potential postoperative problems with any surgical client but are not as likely to occur after an inguinal hernia repair as is urine retention.
A client who has had ulcerative colitis for the past 5 years is admitted to the hospital with an exacerbation of the disease. Which of the following factors was most likely of greatest significance in causing an exacerbation of ulcerative colitis? 1. A demanding and stressful job. 2. Changing to a modified vegetarian diet. 3. Beginning a weight-training program. 4. Walking 2 miles every day.
1. Stressful and emotional events have been clearly linked to exacerbations of ulcerative colitis, although their role in the etiology of the disease has been disproved. A modified vegetarian diet or an exercise program is an unlikely cause of the exacerbation.
A client is recovering from an abdominal-perineal resection. Which of the following measures would most effectively promote wound healing after the perineal drains have been removed? 1. Taking sitz baths. 2. Taking daily showers. 3. Applying warm, moist dressings to the area. 4. Applying a protected heating pad to the area.
1. Sitz baths are an effective way to clean the operative area after an abdominal-perineal resection. Sitz baths bring warmth to the area, improve circulation, and promote healing and cleanliness. Most clients find them comfortable and relaxing. Between sitz baths, the area should be kept clean and dry. A shower will not adequately clean the perineal area. Moist dressings may promote wound contamination and delay healing. A heating pad applied to the area for longer than 20 minutes may cause excessive vasodilation, leading to congestion and discomfort.
The nurse is developing a plan of care for a client with Crohn's disease who is receiving total parenteral nutrition (TPN). Which of the following interventions should the nurse include? Select all that apply. 1. Monitoring vital signs once a shift. 2. Weighing the client daily. 3. Changing the central venous line dressing daily. 4. Monitoring the I.V. infusion rate hourly. 5. Taping all I.V. tubing connections securely.
2, 4, 5. When caring for a client who is receiving TPN, the nurse should plan to weigh the client daily, monitor the I.V. fluid infusion rate hourly (even when using an I.V. fluid pump), and securely tape all I.V. tubing connections to prevent disconnections. Vital signs should be monitored at least every 4 hours to facilitate early detection of complications. It is recommended that the I.V. dressing be changed once or twice per week or when it becomes soiled, loose, or wet.
ILEOSTOMY The nurse is teaching the client how to care for her ileostomy. The client asks the nurse how long she can wear her pouch before changing it. The nurse responds: 1. "The pouch is changed only when it leaks." 2. "You can wear the pouch for about 4 to 7 days." 3. "You should change the pouch every evening before bedtime." 4. "It depends on your activity level and your diet."
2. Unless the pouch leaks, the client can wear her ileostomy pouch for about 4 to 7 days. If leakage occurs, it is important to promptly change the pouch to avoid skin irritation. It is not necessary to change the pouch daily or in the evening. Diet and activity typically do not affect the schedule for changing the pouch.
The nurse assesses the client's stoma during the initial postoperative period. Which of the fololowing observations should be reported immediately to the physician? 1. The stoma is slightly edematous. 2. The stoma is dark red to purple. 3. The stoma oozes a small amount of blood. 4. The stoma does not expel stool.
2. A dark red to purple stoma indicates inadequate blood supply. Mild edema and slight oozing of blood are normal in the early postoperative period. The colostomy would typically not begin functioning until 2 to 4 days after surgery.
A client has just had an inguinal hernior-rhaphy. Which of the following instructions would be most appropriate to include in his discharge plan? 1. Turning, coughing, and deep breathing every 2 hours. 2. Applying an ice bag to the scrotum. 3. Applying a truss before the client ambulates. 4. Maintaining a high Fowler's position while resting.
2. After inguinal herniorrhaphy, an ice bag to the scrotum will help decrease pain and edema. The client is encouraged to turn and deep-breathe, but coughing is not encouraged, to decrease straining on the surgical area. A truss is not needed for support after surgery. While resting, the client may be most comfortable in a semi-Fowler's position, but there is no need to maintain a high Fowler's position.
CANCER OF COLON Which of the following guidelines reflects the current American Cancer Society recommendations for screening for colon cancer in individuals who are not at high risk? 1. Annual digital rectal examination should begin at age 40. 2. Annual fecal testing for occult blood should begin at age 50. 3. Individuals should obtain a baseline barium enema at age 40. 4. Individuals should obtain a baseline colonos-copy at age 45.
2. Annual fecal testing for occult blood should begin at age 50. Annual digital rectal examinations are recommended in men beginning at age 50 to screen for prostate cancer. Baseline barium enemas or colonoscopies are recommended at age 50. Baseline barium enemas and colonoscopies are not performed on individuals in their 40s unless they experience signs or symptoms that indicate the need for such diagnostic testing, or are considered to be at high risk.
Which position would be best for the client in the early postoperative period after a hemorrhoidectomy? 1. High Fowler's. 2. Supine. 3. Side-lying. 4. Trendelenburg's.
3. Positioning in the early postoperative phase should avoid stress and pressure on the operative site. The prone and side-lying positions are ideal from a comfort perspective. A high Fowler's or supine position will place pressure on the operative site and is not recommended. There is no need for Trendelenburg's position.
INGUINAL HERNIA A client who has a history of an inguinal hernia is admitted to the hospital with sudden, severe abdominal pain, vomiting, and abdominal distention. The nurse should assess the client further for which of the following complications? 1. Peritonitis. 2. Incarcerated hernia. 3. Strangulated hernia. 4. Intestinal perforation.
3. The symptoms are indicative of a strangulated hernia. In a strangulated hernia, the hernia cannot be reduced back into the abdominal cavity. The intestinal lumen and the blood supply to the intestine are obstructed, causing an acute intestinal obstruction. Without immediate intervention, necrosis and gangrene may develop. Surgery is required to release the strangulation. Although many of these signs and symptoms are present with peritonitis or perforated bowel, abdominal rigidity, a cardinal sign of peritonitis and perforated bowel, is not mentioned. Therefore, the nurse would not immediately suspect these conditions. An incarcerated hernia refers to a hernia that is irreducible but has not necessarily resulted in an obstruction.
The nurse has an order to administer sulfasalazine (Azulfidine) 2 g. The medication is available in 500-mg tablets. How many tablets should the nurse administer? ________________________ tablets.
4 tablets To administer 2 g sulfasalazine (Azulfidine), the nurse will need to administer 4 tablets.
Which of the following should the nurse interpret as an indication of a complication after the first few days of TPN therapy? 1. Glycosuria. 2. A 1- to 2-pound weight gain. 3. Decreased appetite. 4. Elevated temperature.
4. An elevated temperature can be an indication of an infection at the insertion site or in the catheter. Vital signs should be taken every 2 to 4 hours after initiation of TPN therapy to detect early signs of complications. Glycosuria is to be expected during the first few days of therapy until the pancreas adjusts by secreting more insulin. A gradual weight gain is to be expected as the client's nutritional status improves. Some clients experience a decreased appetite during TPN therapy.
A client refuses to look at or care for her colostomy. Which of the following statements by the nurse would be most appropriate? 1. "It has been 4 days since your surgery and you will soon be discharged. You have to learn to care for your colostomy before you leave the hospital." 2. "I think we will need to teach your husband to care for your colostomy if you are not going to be able to do it." 3. "I understand how you are feeling. It is important for you to feel attractive and you think having a colostomy changes your attractiveness." 4. "I can see that you are upset. Would you like to share your concerns with me?"
4. It is important for the nurse to recognize that individuals go through a grieving process when adjusting to a colostomy. The nurse should be accepting and provide the client with opportunities to share her concerns and feelings when she is ready. Lecturing the client about the need to learn how to care for the colostomy is not productive, nor is attempting to shame her into caring for the colostomy by implying her husband will have to provide the care if she does not. It is not possible for the nurse to understand what the client is feeling.
When planning diet teaching for the client with a colostomy, the nurse should develop a plan that emphasizes which of the following dietary instructions? 1. Foods containing roughage should not be eaten. 2. Liquids are best limited to prevent diarrhea. 3. Clients should experiment to find the diet that is best for them. 4. A high-fiber diet will produce a regular passage of stool.
3. It is best to adjust the diet of a client with a colostomy in a manner that suits the client rather than trying special diets. Severe restriction of rough¬age is not recommended. The client is encouraged to drink 2 to 3 L of fluid per day. A high-fiber diet may produce loose stools.
A client with acute appendicitis develops a fever, tachycardia, and hypotension. Based on these assessment findings, the nurse should further assess the client for which of the following complications? 1. Deficient fluid volume. 2. Intestinal obstruction. 3. Bowel ischemia. 4. Peritonitis.
4. Complications of acute appendicitis are perforation, peritonitis, and abscess development. Signs of the development of peritonitis include abdominal pain and distention, tachycardia, tachypnea, nausea, vomiting, and fever. Because peritonitis can cause hypovolemic shock, hypotension can develop. Deficient fluid volume would not cause a fever. Intestinal obstruction would cause abdominal distention, diminished or absent bowel sounds, and abdominal pain. Bowel ischemia has signs and symptoms similar to those found with intestinal obstruction.
DIVERTICULAR DISEASE Which foods should the nurse encourage a client with diverticulosis to incorporate into the diet? Select all that apply. 1. Bran cereal. 2. Broccoli. 3. Tomato juice. 4. Navy beans. 5. Cheese.
1, 2, 4. Clients with diverticulosis are encouraged to follow a high-fiber diet. Bran, broccoli, and navy beans are foods high in fiber. Tomato juice and cheese are low-residue foods.
A client's ulcerative colitis signs and symptoms have been present for longer than 1 week. The nurse should assess the client for signs and symptoms of which of the following complications? 1. Heart failure. 2. Deep vein thrombosis. 3. Hypokalemia. 4. Hypocalcemia.
3. Excessive diarrhea causes significant depletion of the body's stores of sodium and potassium as well as fluid. The client should be closely monitored for hypokalemia and hyponatremia. Ulcerative colitis does not place the client at risk for heart failure, deep vein thrombosis, or hypocalcemia.
APPENDICITIS A nurse is providing wound care to a client 1 day after the client underwent an appendectomy. A drain was inserted into the incisional site during surgery. Which action should the nurse perform when providing wound care? 1. Remove the dressing and leave the incision open to air. 2. Remove the drain if wound drainage is minimal. 3. Gently irrigate the drain to remove exudate. 4. Clean the area around the drain moving away from the drain.
4. The nurse should gently clean the area around the drain by moving in a circular motion away from the drain. Doing so prevents the introduction of microorganisms to the wound and drain site. The incision cannot be left open to air as long as the drain is intact. The nurse should note the amount and character of wound drainage, but the surgeon will determine when the drain should be removed. Surgical wound drains are not irrigated.
The client with colon cancer has an abdominal-perineal resection with a colostomy. Which of the following nursing interventions is most appropriate for this client in the postoperative period? 1. Maintain the client in a semi-Fowler's position. 2. Assist the client with warm sitz baths. 3. Administer 30 ml of milk of magnesia to stimulate colostomy activity. 4. Remove the ostomy pouch as needed so the stoma can be assessed.
2. Appropriate nursing interventions after an abdominal-perineal resection with a colostomy include assisting the client with warm sitz baths three to four times a day to clean the perineal incision. The client will be more comfortable assuming a side-lying position because of the perineal incision. It would be inappropriate to administer milk of magnesia to stimulate colostomy activity. Stool passage will begin as peristalsis returns. It is not necessary or desirable to change the ostomy pouch daily to assess the stoma. The ostomy pouch should be transparent to allow easy observation of the stoma and drainage.
The nurse should teach the client with diverticulitis to integrate which of the following into a daily routine at home? 1. Using enemas to relieve constipation. 2. Decreasing fluid intake to increase the formed consistency of the stool. 3. Eating a high-fiber diet when symptomatic with diverticulitis. 4. Refraining from straining and lifting activities.
4. Clients with diverticular disease should refrain from any activities, such as lifting, straining, or coughing, that increase intra-abdominal pressure and may precipitate an attack. Enemas are contraindicated because they increase intestinal pressure. Fluid intake should be increased, rather than decreased, to promote soft, formed stools. A low-fiber diet is used when inflammation is present.
Before abdominal surgery for an intestinal obstruction, the nurse monitors the client's urine output and finds that the total output for the past 2 hours was 35 mL. The nurse then assesses the client's total intake and output over the last 24 hours and notes that he had 2,000 mL of I.V. fluid for intake, 500 mL of drainage from the nasogastric tube, and 700 mL of urine for a total output of 1,200 mL. This would indicate which of the following? 1. Decreased renal function. 2. Inadequate pain relief. 3. Extension of the obstruction. 4. Inadequate fluid replacement.
4. Considering that there is usually 1 L of insensible fluid loss, this client's output exceeds his intake (intake, 2,000 mL; output, 2,200 mL), indicating deficient fluid volume. The kidneys are concentrating urine in response to low circulating volume, as evidenced by a urine output of less than 30 mL/ hour. This indicates that increased fluid replacement is needed. Decreasing urine output can be a sign of decreased renal function, but the data provided suggest that the client is dehydrated. Pain does not affect urine output. There are no data to suggest that the obstruction has worsened.
A client who has ulcerative colitis says to the nurse, "I can't take this anymore! I'm constantly in pain, and I can't leave my room because I need to stay by the toilet. I don't know how to deal with this." Based on these comments, an appropriate nursing diagnosis for this client would be: 1. Impaired physical mobility related to fatigue. 2. Disturbed thought processes related to pain. 3. Social isolation related to chronic fatigue. 4. Ineffective coping related to chronic abdominal pain.
4. It is not uncommon for clients with ulcerative colitis to become apprehensive and upset about the frequency of stools and the presence of abdominal cramping. During these acute exacerbations, clients need emotional support and encouragement to verbalize their feelings about their chronic health concerns and assistance in developing effective coping methods. The client has not expressed feelings of fatigue or isolation or demonstrated disturbed thought processes.
The nurse is conducting a community presentation on the early detection of colon cancer. Which of the following should the nurse encourage members of the audience to report to their health care providers? Select all that apply. 1. Fatigue. 2. Unexplained weight loss with adequate nutritional intake. 3. Rectal bleeding. 4. Bowel changes. 5. Positive fecal occult blood testing.
1, 2, 3, 4, 5. Colorectal cancer may be asymptomatic, or symptoms vary according to the location of the tumor and the extent of involvement. Fatigue, weight loss, and iron deficiency anemia, even without rectal bleeding or bowel changes, should prompt investigation for colorectal cancer. Fecal occult blood testing commonly reveals evidence of carcinoma when the client is otherwise asymptomatic.
Using a sliding-scale schedule, the nurse is preparing to administer an evening dose of regular insulin to a client who is receiving total parenteral nutrition (TPN). Which action is most appropriate for the nurse to take to determine the amount of insulin to give? 1. Base the dosage on the glucometer reading of the client's glucose level obtained immediately before administering the insulin. 2. Base the dosage on the fasting blood glucose level obtained earlier in the day. 3. Calculate the amount of TPN fluid the client has received since the last dose of insulin and adjust the dosage accordingly. 4. Assess the client's dietary intake for the evening meal and snack and adjust the dosage accordingly.
1. When using a sliding-scale insulin schedule, the nurse obtains a glucometer reading of the client's blood glucose level immediately before giving the insulin and bases the dosage on those findings. The fasting blood glucose level obtained earlier in the day is not relevant to an evening sliding-scale insulin dosage. The nurse cannot calculate insulin dosage by assessing the amount of TPN intake or dietary intake.
A client with colon cancer is having a barium enema. The nurse should instruct the client to take which of the following after the procedure is completed? 1. Laxative. 2. Anticholinergic. 3. Antacid. 4. Demulcent.
1. After a barium enema, a laxative is ordinarily prescribed. This is done to promote elimination of the barium. Retained barium predisposes the client to constipation and fecal impaction. Anti-cholinergic drugs decrease gastrointestinal motility. Antacids decrease gastric acid secretion. Demul¬cents soothe mucous membranes of the gastrointestinal tract and are used to treat diarrhea.
Which of the following would be an expected outcome for a client who is recovering from an abdominal-perineal resection with a colostomy? The client will: 1. Maintain a fluid intake of 3,000 ml/day. 2. Eliminate fiber from the diet. 3. Limit physical activity to light exercise. 4. Accept that sexual activity will be diminished.
1. An expected outcome is that the client will maintain a fluid intake of 3,000 mL/day unless contraindicated. There is no need to eliminate fiber from the diet; the client can eat whatever foods are desired, avoiding those that are bothersome. Physical activity does not need to be limited to light exercise. The client can resume normal activities as tolerated, usually within 6 to 8 weeks. The client's sexual activity may be affected, but it does not need to be diminished.
The nurse is assigning clients for the evening shift. Which of the following clients are appropriate for the nurse to assign to a licensed practical nurse to provide client care? Select all that apply. 1. A client with Crohn's disease who is receiving total parenteral nutrition (TPN). 2. A client who underwent inguinal hernia repair surgery 3 hours ago. 3. A client with an intestinal obstruction who needs a Cantor tube inserted. 4. A client with diverticulitis who needs teaching about his take-home medications. 5. A client who is experiencing an exacerbation of his ulcerative colitis.
2, 5. The nurse should consider client needs and scope of practice when assigning staff to provide care. The client who is recovering from inguinal hernia repair surgery and the client who is experiencing an exacerbation of his ulcerative colitis are appropriate clients to assign to a licensed practical nurse as the care they require fall within the scope of practice for a licensed practical nurse. It is not within the scope of practice for the licensed practical nurse to administer TPN, insert nasoenteric tubes, or provide client teaching related to medications.
Postoperative nursing care for a client after an appendectomy should include which of the following? 1. Administering sitz baths four times a day. 2. Noting the first bowel movement after surgery. 3. Limiting the client's activity to bathroom privileges. 4. Measuring abdominal girth every 2 hours.
2. Noting the client's first bowel movement after surgery is important because this indicates that normal peristalsis has returned. Sitz baths are used after rectal surgery, not appendectomy. Ambulation is started the day of surgery and is not confined to bathroom privileges. The abdomen should be auscultated for bowel sounds and palpated for softness, but there is no need to measure the girth every 2 hours.
A client with ulcerative colitis is to take sulfasalazine (Azulfidine). Which of the following instructions should the nurse provide for the client about taking this medication at home? Select all that apply. 1. Drink enough fluids to maintain a urine output of at least 1,200- 1,500 mL per day. 2. Discontinue therapy if symptoms of acute intolerance develop and notify the health care provider. 3. Stop taking the medication if the urine turns orange-yellow. 4. Avoid activities that require alertness. 5. If dose is missed, skip and continue with the next dose.
1, 2, 4. Sulfasalazine may cause dizziness and the nurse should caution the client to avoid driving or other activities that require alertness until response to medication is known. If symptoms of acute intolerance (cramping, acute abdominal pain, bloody diarrhea, fever, headache, rash) occur, the client should discontinue therapy and notify the health care provider immediately. Fluid intake should be sufficient to maintain a urine output of at least 1,200- 1,500 mL daily to prevent crystalluria and stone formation. The nurse can also inform the client that this medication may cause orange-yellow discoloration of urine and skin, which is not significant and does not require the client to stop taking the medication. The nurse should instruct the client to take missed doses as soon as remembered unless it is almost time for the next dose.
A client with diverticulitis has developed peritonitis following diverticular rupture. The nurse should assess the client to determine which of the following? Select all that apply. 1. Percuss the abdomen to note resonance and tympany. 2. Percuss the liver to note lack of dullness. 3. Monitor the vital signs for fever, tachypnea, and bradycardia. 4. Assess presence of polyphagia and polydipsia. 5. Auscultate bowel sounds to note frequency.
1, 2, 5. Assessment during peritonitis will reveal fever, tachypnea, and tachycardia. The abdomen becomes rigid with rebound tenderness and there will be absent bowel sounds. Percussion will show resonance and tympany indicating paralytic ileus; loss of liver dullness may indicate free air in the abdomen. There is anorexia, nausea, and vomiting as peristalsis decreases.
INTESTINAL OBSTRUCTION A nurse is assessing a client who has been admitted with a diagnosis of an obstruction in the small intestine. The nurse should assess the client for? Select all that apply. 1. Projectile vomiting. 2. Significant abdominal distention. 3. Copious diarrhea. 4. Rapid onset of dehydration. 5. Increased bowel sounds.
1, 4, 5. Signs and symptoms of intestinal obstructions in the small intestine may include projectile vomiting and rapidly developing dehydration and electrolyte imbalances. The client will also have increased bowel sounds, usually high-pitched and tinkling. The client would not normally have diarrhea and would have minimal abdominal distention. Pain is intermittent, being relieved by vomiting. Intestinal obstructions in the large intestine usually evolve slowly, produce persistent pain, and vomiting is less common. Clients with a large-intestine obstruction may develop obstipation and significant abdominal distention.
A client is admitted with a bowel obstruction. The client has nausea, vomiting, and crampy abdominal pain. The physician has written orders for the client to be up ad lib, to have narcotics for pain, to have a nasogastric tube inserted if needed, and for I.V. Ringer's Lactate and hyperalimentation fluids. The nurse should do the following in order of priority from first to last: 1. Assist with ambulation to promote peristalsis 2. Administer Ringer's Lactate 3. Insert a nasogastric tube. 4. Start and infusion of hyperalimentation fluids.
1,2,3,4 The nurse should first help the client ambulate to try to induce peristalsis; this may be effective and require the least amount of invasive procedures. I.V. fluid therapy can be done to correct fluid and electrolyte imbalances (sodium and potassium), and normal saline or Ringer's Lactate to correct interstitial fluid deficit. Nasogastric (NG) decompression of G.I. tract to reduce gastric secretions and nasointestinal tubes may also be used. Hyperalimentation can be used to correct protein deficiency from chronic obstruction, paralytic ileus, or infection.
A client with ulcerative colitis expresses serious concerns about her career as an attorney because of the effects of stress on ulcerative colitis. Which of the following nursing interventions will be most helpful to the client? 1. Review her current coping mechanisms and develop alternatives, if needed. 2. Suggest a less stressful career in which she would still use her education and experience. 3. Suggest that she ask her colleagues to help decrease her stress by giving her the easier cases. 4. Prepare family members for the fact that she will have to work part-time.
1. A client with ulcerative colitis need not curtail career goals. Self-care is the cornerstone of long-term management, and learning to cope with and modify stressors will enable the client to live with the disease. Giving up a desired career could discourage and even depress the client. Placing the responsibility for minimizing stressors at work in the hands of others leads to a feeling of loss of control and decreases the sense of responsibility needed for sound self-care. Working part-time rather than full-time is unnecessary.
The nurse is aware that the diagnostic tests typically ordered for acute diverticulitis do not include a barium enema. The reason for this is that a barium enema: 1. Can perforate an intestinal abscess. 2. Would greatly increase the client's pain. 3. Is of minimal diagnostic value in diverticulitis. 4. Is too lengthy a procedure for the client to tolerate.
1. Barium enemas and colonoscopies are contraindicated in clients with acute diverticulitis because they can lead to perforation of the colon and peritonitis. A barium enema may be ordered after the client has been treated with antibiotic therapy and the inflammation has subsided. A barium enema is diagnostic in diverticulitis. A barium enema could increase the client's pain; however, that is not a reason for excluding this test. The client may be able to tolerate the procedure but the concern is the potential for perforation of the intestine.
A client with diverticular disease is receiving psyllium hydrophilic mucilloid (Metamucil). The drug has been effective when the client tells the nurse that he: 1. Passes stool without cramping. 2. Does not have diarrhea any longer. 3. Is not as anxious as he was. 4. Does not expel gas like he used to.
1. Diverticular disease is treated with a high-fiber diet and bulk laxatives such as psyllium hydrophilic mucilloid (Metamucil). Fiber decreases the intraluminal pressure and makes it easier for stool to pass through the colon. Bulk laxatives do not manage diarrhea, anxiety or relieve gas formation.
The physician orders intestinal decompression with a Cantor tube for a client with an intestinal obstruction. In order to determine effectiveness of intestinal decompression the nurse should evaluate the client to determine if: 1. Fluid and gas have been removed from the intestine. 2. The client has had a bowel movement. 3. The client's urinary output is adequate. 4. The client can sit up without pain.
1. Intestinal decompression is accomplished with a Cantor, Harris, or Miller-Abbott tube. These 6- to 10-foot tubes are passed into the small intestine to the obstruction. They remove accumulated fluid and gas, relieving the pressure. The client will not have an adequate bowel movement until the obstruction is removed. The pressure from the distended intestine should not obstruct urinary output. While the client may be able to more easily sit up, and the pain caused by the intestinal pressure will be less, these are not the primary indicators for successful intestinal decompression.
The nurse administers fat emulsion solution during TPN as ordered based on the understanding that this type of solution: 1. Provides essential fatty acids. 2. Provides extra carbohydrates. 3. Promotes effective metabolism of glucose. 4. Maintains a normal body weight.
1. The administration of fat emulsion solution provides additional calories and essential fatty acids to meet the body's energy needs. Fatty acids are lipids, not carbohydrates. Fatty acids do not aid in the metabolism of glucose. Although they are necessary for meeting the complete nutritional needs of the client, fatty acids do not necessarily help a client maintain normal body weight.
TPN is ordered for a client with Crohn's disease. Which of the following indicate the TPN soloution is having an intended outcome? 1. There is increased cell nutrition. 2. The client does not have metabolic acidosis. 3. The client is hydrated. 4. The client is in a negative nitrogen balance.
1. The goal of TPN is to meet the client's nutritional needs. TPN is not used to treat metabolic acidosis; ketoacidosis can actually develop as a result of administering TPN. TPN is a hypertonic solution containing carbohydrates, amino acids, electrolytes, trace elements, and vitamins. It is not used to meet the hydration needs of clients. TPN is administered to provide a positive nitrogen balance.
The nurse instructs the client who has had a hemorrhoidectomy not to use sitz baths until at least 12 hours postoperatively to avoid inducing which of the following complications? 1. Hemorrhage. 2. Rectal spasm. 3. Urine retention. 4.Constipation.
1. Applying heat during the immediate post-operative period may cause hemorrhage at the surgical site. Moist heat may relieve rectal spasms after bowel movements. Urine retention caused by reflex spasm may also be relieved by moist heat. Increasing fiber and fluid in the diet can help prevent constipation.
Which of the following skin preparations would be best to apply around the client's colostomy? 1. Karaya. 2. Petroleum jelly. 3.Cornstarch. 4. Antiseptic cream.
1. Karaya and Stomahesive are both effective agents for protecting the skin around a colostomy. They keep the skin healthy and prevent skin irritation from stoma drainage. Petroleum jelly, corn¬starch, and antiseptic creams do not protect the skin adequately and may prevent an adequate seal between the skin and the colostomy bag.
Which of the following should be a priority focus of care for a client experiencing an exacerbation of Crohn's disease? 1. Encouraging regular ambulation. 2. Promoting bowel rest. 3. Maintaining current weight. 4. Decreasing episodes of rectal bleeding.
2. A priority goal of care during an acute exacerbation of Crohn's disease is to promote bowel rest. This is accomplished through decreasing activity, encouraging rest, and initially placing client on nothing-by-mouth status while maintaining nutritional needs parenterally. Regular ambulation is important, but the priority is bowel rest. The client will probably lose some weight during the acute phase of the illness. Diarrhea is nonbloody in Crohn's disease, and episodes of rectal bleeding are not expected.
Which of the following diets would be most appropriate for the client with ulcerative colitis? 1. High-calorie, low-protein. 2. High-protein, low-residue. 3. Low-fat, high-fiber. 4. Low-sodium, high-carbohydrate.
2. Clients with ulcerative colitis should follow a well-balanced high-protein, high-calorie, low-residue diet, avoiding such high-residue foods as whole-wheat grains, nuts, and raw fruits and vegetables. Clients with ulcerative colitis need more protein for tissue healing and should avoid excess roughage. There is no need for clients with ulcerative colitis to follow low-sodium diets.
Which of the following interventions should the nurse include in the client's plan of care to prevent complications associated with TPN administered through a central line? 1. Use a clean technique for all dressing changes. 2. Tape all connections of the system. 3. Encourage bed rest. 4. Cover the insertion site with a moisture-proof dressing.
2. Complications associated with administration of TPN through a central line include infection and air embolism. To prevent these complications, strict aseptic technique is used for all dressing changes, the insertion site is covered with an air-occlusive dressing, and all connections of the system are taped. Ambulation and activities of daily living are encouraged and not limited during the administration of TPN.
Which goal for the client's care should take priority during the first days of hospitalization for an exacerbation of ulcerative colitis? 1. Promoting self-care and independence. 2. Managing diarrhea. 3. Maintaining adequate nutrition. 4. Promoting rest and comfort.
2. Diarrhea is the primary symptom in an exacerbation of ulcerative colitis, and decreasing the frequency of stools is the first goal of treatment. The other goals are ongoing and will be best achieved by halting the exacerbation. The client may receive antidiarrheal agents, antispasmodic agents, bulk hydrophilic agents, or anti-inflammatory drugs.
INFLAMMATORY BOWL DISEASE A client has been placed on long-term sulfasalazine (Azulfidine) therapy for treatment of his ulcerative colitis. The nurse should encourage the client to eat which of the following foods to help avoid the nutrient deficiencies that may develop as a result of this medication? 1. Citrus fruits. 2. Green, leafy vegetables. 3. Eggs. 4. Milk products.
2. In long-term sulfasalazine therapy, the client may develop folic acid deficiency. The client can take folic acid supplements, but the nurse should also encourage the client to increase the intake of folic acid in his diet. Green, leafy vegetables are a good source of folic acid. Citrus fruits, eggs, and milk products are not good sources of folic acid.
A client with Crohn's disease has concentrated urine, decreased urinary output, dry skin with decreased turgor, hypotension, and weak, thready pulses. The nurse should do which of the following first? 1. Encourage the client to drink at least 1,000 mL per day. 2. Provide parenteral rehydration therapy ordered by the physician. 3. Turn and reposition every 2 hours. 4. Monitor vital signs every shift.
2. Initially, the extracellular fluid (ECF) volume with isotonic I.V. fluids until adequate circulating blood volume and renal perfusion are achieved. Vital signs should be monitored as parenteral and oral rehydration are achieved. Oral fluid intake should be greater than 1,000 mL/ day. Turning and repositioning the client at regular intervals aids in the prevention of skin breakdown, but it is first necessary to rehydrate this client.
A client newly diagnosed with ulcerative colitis who has been placed on steroids asks the nurse why steroids are prescribed. The nurse shuld tell the client? 1. "Ulcerative colitis can be cured by the use of steroids." 2. "Steroids are used in severe flare-ups because they can decrease the incidence of bleeding." 3. "Long-term use of steroids will prolong periods of remission." 4.. "The side effects of steroids outweigh their benefits to clients with ulcerative colitis."
2. Steroids are effective in management of the acute symptoms of ulcerative colitis. Steroids do not cure ulcerative colitis, which is a chronic disease. Long-term use is not effective in prolonging the remission and is not advocated. Clients should be assessed carefully for side effects related to steroid therapy, but the benefits of short-term steroid therapy usually outweigh the potential adverse effects.
A client with inflammatory bowel disease is receiving total parenteral nutrition (TPN). The basic component of the client's TPN solution is most likely to be: 1. An isotonic dextrose solution. 2. A hypertonic dextrose solution. 3. A hypotonic dextrose solution. 4. A colloidal dextrose solution.
2. The TPN solution is usually a hypertonic dextrose solution. The greater the concentration of dextrose in solution, the greater the tonicity. Hypertonic dextrose solutions are used to meet the body's calorie demands in a volume of fluid that will not overload the cardiovascular system. An isotonic dextrose solution (e.g., 5% dextrose in water) or a hypotonic dextrose solution will not provide enough calories to meet metabolic needs. Colloids are plasma expanders and blood products and are not used in TPN.
After insertion of a nasoenteric tube, the nurse should place the client in which position? 1. Supine. 2. Right side-lying. 3. Semi-Fowler's. 4. Upright in a bedside chair.
2. The client is placed in a right side-lying position to facilitate movement of the mercury-weighted tube through the pyloric sphincter. After the tube is in the intestine, the client is turned from side to side or encouraged to ambulate to facilitate tube movement through the intestinal loops. Placing the client in the supine or semi-Fowler's position, or having the client sitting out of bed in a chair will not facilitate tube progression.
The nurse finds the client who has had an ileostomy crying. The client explains to the nurse, "I'm upset because I know I won't be able to have children now that I have an ileostomy." Which of the following would be the best response for the nurse? 1. "Many women with ileostomies decide to adopt. Why don't you consider that option?" 2. "Having an ileostomy does not necessarily mean that you can't bear children. Let's talk about your concerns." 3. "I can understand your reasons for being upset. Having children must be important to you." 4. "I'm sure you will adjust to this situation with time. Try not to be too upset."
2. The fact that the client has an ileostomy does not necessarily mean that she cannot get pregnant and bear children. It may be recommended, however, that the number of pregnancies be limited. Women of childbearing age should be encouraged to discuss their concerns with their physician. Discussing their concerns about sexual functioning and pregnancy will help decrease fears and anxiety. Empathizing or telling the woman that she can adopt does not address her concerns. Her current fears may be based on erroneous understanding. Telling the client that she will adjust to the situation ignores her concerns.
A client who is scheduled for an ileostomy has an order for oral neomycin (Mycifradin) to be administered before surgery. The intended outcome of administering oral neomycin before surgery is to: 1. Prevent postoperative bladder infection. 2. Reduce the number of intestinal bacteria. 3. Decrease the potential for postoperative hypostatic pneumonia. 4. Increase the body's immunologic response to the stressors of surgery.
2. The rationale for the administration of oral neomycin is to decrease intestinal bacteria and thereby decrease the potential for peritonitis and wound infection postoperatively. Neomycin will not alter the client's potential for developing a urinary or respiratory infection. Neomycin does not affect the body's immune system.
The nurse notes that the sterile, occlusive dressing on the central catheter insertion site of a client receiving total parenteral nutrition (TPN) is moist. The client is breathing easily with no abnormal breath sounds. The nurse should do the following in order of what priority from first to last? 1. Change dressing per institutional policy. 2. Culture drainage at insertion site. 3. Notify physician. 4. Position rolled towel under client's back, parallel to the spine.
3, 4, 2, 1. A potential complication of receiving TPN is leakage or catheter puncture; notify the physician immediately and prepare for changing of the catheter. If pneumothorax is suspected, position a rolled towel under the client's back. If there is drainage at the insertion site, culture the drainage and change the dressing using sterile technique.
After instructing a client with diverticulosis about appropriate self-care activities, which of the following client comments indicate effective teaching? Select all that apply. 1. "With careful attention to my diet, my diverticulosis can be cured." 2. "Using a cathartic laxative weekly is okay to control bowel movements." 3. "I should follow a diet that's high in fiber." 4. "It is important for me to drink at least 2,000 mL of fluid every day." 5. "I should exercise regularly."
3, 4, 5. Clients who have diverticulosis should be instructed to maintain a diet high in fiber and, unless contraindicated, should increase their fluid intake to a minimum of 2,000 mL/ day. Participating in a regular exercise program is also strongly encouraged. Diverticulosis can be controlled with treatment but cannot be cured. Clients should be instructed to avoid the regular use of cathartic laxatives. Bulk laxatives and stool softeners may be helpful to maintain regularity and decrease straining.
The client asks the nurse, "Is it really possible to lead a normal life with an ileostomy?" Which action by the nurse would be the most effective to address this question? 1. Have the client talk with a member of the clergy about these concerns. 2. Tell the client to worry about those concerns after surgery. 3. Arrange for a person with an ostomy to visit the client preoperatively. 4. Notify the surgeon of the client's question.
3. If the client agrees, having a visit by a person who has successfully adjusted to living with an ileostomy would be the most helpful measure. This would let the client actually see that typical activities of daily living can be pursued postoperatively. Someone who has felt some of the same concerns can answer the client's questions. A visit from the clergy may be helpful to some clients but would not provide this client with the information sought. Disregarding the client's concerns is not helpful. Although the physician should know about the client's concerns, this in itself will not reassure the client about life after an ileostomy.
A client has returned to the medical surgical unit after having surgery to create an ileostomy. Which goal has the highest priority at this time? 1. Providing relief from constipation. 2. Assisting the client with self-care activities. 3. Maintaining fluid and electrolyte balance. 4. Minimizing odor formation.
3. A high-priority outcome after ileostomy surgery is the maintenance of fluid and electrolyte balance. The client will experience continuous liquid to semiliquid stools. The client should be engaged in self-care activities, and minimizing odor formation is important; however, these goals do not take priority over maintaining fluid and electrolyte balance.
The physician prescribes sulfasalazine (Azulfidine) for the client with ulcerative colitis to continue taking at home. Which instruction should the nurse give the client about taking this medication? 1. Avoid taking it with food. 2. Take the total dose at bedtime. 3. Take it with a full glass (240 mL) of water. 4. Stop taking it if urine turns orange-yellow.
3. Adequate fluid intake of at least 8 glasses a day prevents crystalluria and stone formation during sulfasalazine therapy. Sulfasalazine can cause gastrointestinal distress and is best taken after meals and in equally divided doses. Sulfasalazine gives alkaline urine an orange-yellow color, but it is not necessary to stop the drug when this occurs.
The nurse should instruct the client with an ileostomy to report which of the following signs and symptoms immediately? 1. Passage of liquid stool from the stoma. 2. Occasional presence of undigested food in the effluent. 3. Absence of drainage from the ileostomy for 6 or more hours. 4. Temperature of 99.8 ° F (37.7 ° C).
3. Any sudden decrease in drainage or onset of severe abdominal pain should be reported to the physician immediately because it could mean that an obstruction has developed. The ileostomy drains liquid stool at frequent intervals throughout the day. Undigested food may be present at times. A temperature of 99.8 ° F is not necessarily abnormal or a cause for concern.
Three weeks after the client has had an ileostomy, the nurse is following up with instruction about using a skin barrier around the stoma at all times. The client has been applying the skin barrier correctly when: 1. There is no odor from the stoma. 2. The client is adequately hydrated. 3. There is no skin irritation around the stoma. 4. The client only changes the ostomy pouch once a day.
3. Because of high concentrations of digestive enzymes, ileostomy effluent is irritating to skin and can cause excoriation and ulceration. Some form of protection must be used to keep the effluent from contacting the skin. A skin barrier does not decrease odor formation; odor is controlled by diet. The barrier does not affect the client's hydration status, and the nurse can encourage the client to have an adequate daily intake of fluids. Pouches are usually worn for 4 to 7 days before being changed.
Which of the following laboratory findings would the nurse expect to find in a client with diverticulitis? 1. Elevated red blood cell count. 2. Decreased platelet count. 3. Elevated white blood cell count. 4. Elevated serum blood urea nitrogen concentration.
3. Because of the inflammatory nature of diverticulitis, the nurse would anticipate an elevated white blood cell count. The remaining laboratory findings are not associated with diverticulitis. Elevated red blood cell counts occur in clients with polycythemia vera or fluid volume deficit. Decreased platelet counts can occur as a result of aplastic anemias or malignant blood disorders, as an adverse effect of some drugs, and as a result of some heritable conditions. Elevated serum blood urea nitrogen concentration is usually associated with renal conditions.
A client who has ulcerative colitis has persistent diarrhea. He is thin and has lost 12 lb since the exacerbation of his ulcerative colitis. Which of the following will be most effective in helping the client meet his nutritional needs? 1. Continuous enteral feedings. 2. Following a high-calorie, high-protein diet. 3. Total parenteral nutrition (TPN). 4. Eating six small meals a day.
3. Food will be withheld from the client with severe symptoms of ulcerative colitis to rest the bowel. To maintain the client's nutritional status, the client will be started on TPN. Enteral feedings or dividing the diet into six small meals does not allow the bowel to rest. A high-calorie, high-protein diet will worsen the client's symptoms.
A client who has a history of Crohn's disease is admitted to the hospital with fever, diarrhea, cramping, abdominal pain, and weight loss. The nurse should monitor the client for: 1. Hyperalbuminemia. 2. Thrombocytopenia. 3. Hypokalemia. 4. Hypercalcemia.
3. Hypokalemia is the most expected laboratory finding owing to the diarrhea. Hypoalbuminemia can also occur in Crohn's disease; however, the client's potassium level is of greater importance at this time because a low potassium level can cause cardiac arrest. Anemia is an expected development, but thrombocytopenia is not. Calcium levels are not affected.
A client is scheduled for an ileostomy. Which of the following interventions would be most helpful in preparing the client psychologically for the surgery? 1. Include family members in preoperative teaching sessions. 2. Encourage the client to ask questions about managing an ileostomy. 3. Provide a brief, thorough explanation of all preoperative and postoperative procedures. 4. Invite a member of the ostomy association to visit the client.
3. Providing explanations of preoperative and postoperative procedures helps the client prepare and understand what to expect. It also provides an opportunity for the client to share concerns. Including family members in the teaching sessions is beneficial but does not focus on the client's psychological preparation. Encouraging the client to ask questions about managing the ileostomy may be rushing the client psychologically into accepting the change in body image and function. The client may need time to first handle the stress of surgery and then observe the care of the ileostomy by others before it is appropriate to begin discussing self-management. The nurse should gently explore whether the client is ready to ask questions about management throughout the hospitalization. The client should have the opportunity to express concerns and to agree to an ostomy association visitor before an invitation is extended.
TOTAL PARENTERAL NUTRITION The nurse is changing the subclavian dressing of a client who is receiving total parenteral nutrition. When assessing the catheter insertion site, the nurse notes the presence of yellow drainage from around the sutures that are anchoring the catheter. Which action should the nurse take first? 1. Clean the insertion site and redress the area. 2. Document assessment findings in the client's chart. 3. Obtain a culture specimen of the drainage. 4. Notify the physician.
3. The nurse should first obtain a culture specimen. The presence of drainage is a potential indication of an infection and the catheter may need to be removed. A culture specimen should be obtained and sent for analysis so that treatment can be promptly initiated. Since removing the catheter will be required in the presence of an infection, the nurse would not clean and redress the area. After the culture report is obtained, the nurse should notify the physician and document all assessments and client care activities in the client's record.
The nurse is admitting a client with acute appendicitis to the emergency department. The client has abdominal pain of 10 on a pain scale of 1 to 10. The client will be going to surgery as soon as possible. The nurse should: 1. Contact the surgeon to request an order for a narcotic for the pain. 2. Maintain the client in a recumbent position. 3. Place the client on nothing-by-mouth (NPO) status. 4. Apply heat to the abdomen in the area of the pain.
3. The nurse should place the client on NPO status in anticipation of surgery. The nurse can initiate pain relief strategies, such as relaxation techniques, but the surgeon will likely not order narcotic medication prior to surgery. The nurse can place the client in a position that is most comfortable for the client. Heat is contraindicated because it may lead to perforation of the appendix.
The nurse teaches the client who has had rectal surgery the proper timing for sitz baths. The nurse knows that the client has understood the teaching when the client states that it is most important to take a sitz bath: 1. First thing each morning. 2. As needed for discomfort. 3. After a bowel movement. 4. At bedtime.
3. Adequate cleaning of the anal area is difficult but essential. After rectal surgery, sitz baths assist in this process, so the client should take a sitz bath after a bowel movement. Other times are dictated by client comfort.
