Stress: Peritonitis

A female patient is awaiting surgery for acute peritonitis. Which action will the nurse include in the plan of care? a. Position patient with the knees flexed. b. Avoid use of opioids or sedative drugs. c. Offer frequent small sips of clear liquids. d. Assist patient to breathe deeply and cough.

ANS: A There is less peritoneal irritation with the knees flexed, which will help decrease pain. Opioids and sedatives are typically given to control pain and anxiety. Preoperative patients with peritonitis are given IV fluids for hydration. Deep breathing and coughing will increase the patients discomfort. DIF: Cognitive Level: Apply (application) REF: 975 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A 33-year-old male patient with a gunshot wound to the abdomen undergoes surgery, and a colostomy is formed as shown in the accompanying figure. Which information will be included in patient teaching? a. Stool will be expelled from both stomas. b. This type of colostomy is usually temporary. c. Soft, formed stool can be expected as drainage. d. Irrigations can regulate drainage from the stomas.

ANS: B A loop, or double-barrel stoma, is usually temporary. Stool will be expelled from the proximal stoma only. The stool from the transverse colon will be liquid and regulation through irrigations will not be possible. DIF: Cognitive Level: Apply (application) REF: 990 | 991 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

The nurse preparing for the annual physical exam of a 50-year-old man will plan to teach the patient about a. endoscopy. b. colonoscopy. c. computerized tomography screening. d. carcinoembryonic antigen (CEA) testing.

ANS: B At age 50, individuals with an average risk for colorectal cancer (CRC) should begin screening for CRC. Colonoscopy is the gold standard for CRC screening. The other diagnostic tests are not recommended as part of a routine annual physical exam at age 50. DIF: Cognitive Level: Apply (application) REF: 987 TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance

A patient in the emergency department has just been diagnosed with peritonitis caused by a ruptured diverticulum. Which prescribed intervention will the nurse implement first? a. Insert a urinary catheter to drainage. b. Infuse metronidazole (Flagyl) 500 mg IV. c. Send the patient for a computerized tomography scan. d. Place a nasogastric (NG) tube to intermittent low suction.

ANS: B Because peritonitis can be fatal if treatment is delayed, the initial action should be to start antibiotic therapy (after any ordered cultures are obtained). The other actions can be done after antibiotic therapy is initiated. DIF: Cognitive Level: Apply (application) REF: 975 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

The nurse is assessing a 31-year-old female patient with abdominal pain. Th nurse,who notes that there is ecchymosis around the area of umbilicus, will document this finding as a. Cullen sign. b. Rovsing sign. c. McBurney sign. d. Grey-Turners signt.

ANS: B Cullen sign is ecchymosis around the umbilicus. Rovsing sign occurs when palpation of the left lower quadrant causes pain in the right lower quadrant. Deep tenderness at McBurneys point (halfway between the umbilicus and the right iliac crest), known as McBurneys sign, is a sign of acute appendicitis. DIF: Cognitive Level: Understand (comprehension) REF: 973 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

After change-of-shift report, which patient should the nurse assess first? a. 40-year-old male with celiac disease who has frequent frothy diarrhea b. 30-year-old female with a femoral hernia who has abdominal pain and vomiting c. 30-year-old male with ulcerative colitis who has severe perianal skin breakdown d. 40-year-old female with a colostomy bag that is pulling away from the adhesive wafer

ANS: B Pain and vomiting with a femoral hernia suggest possible strangulation, which will necessitate emergency surgery. The other patients have less urgent problems. DIF: Cognitive Level: Analyze (analysis) REF: 983 OBJ: Special Questions: Multiple Patients; Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

A 58-year-old man with blunt abdominal trauma from a motor vehicle crash undergoes peritoneal lavage. If the lavage returns brown fecal drainage, which action will the nurse plan to take next? a. Auscultate the bowel sounds. b. Prepare the patient for surgery. c. Check the patients oral temperature. d. Obtain information about the accident.

ANS: B Return of brown drainage and fecal material suggests perforation of the bowel and the need for immediate surgery. Auscultation of bowel sounds, checking the temperature, and obtaining information about the accident are appropriate actions, but the priority is to prepare to send the patient for emergency surgery. DIF: Cognitive Level: Apply (application) REF: 973 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A 26-year-old woman is being evaluated for vomiting and abdominal pain. Which question from the nurse will be most useful in determining the cause of the patients symptoms? a. What type of foods do you eat? b. Is it possible that you are pregnant? c. Can you tell me more about the pain? d. What is your usual elimination pattern?

ANS: C A complete description of the pain provides clues about the cause of the problem. Although the nurse should ask whether the patient is pregnant to determine whether the patient might have an ectopic pregnancy and before any radiology studies are done, this information is not the most useful in determining the cause of the pain. The usual diet and elimination patterns are less helpful in determining the reason for the patients symptoms. DIF: Cognitive Level: Apply (application) REF: 971 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

Four hours after a bowel resection, a 74-year-old male patient with a nasogastric tube to suction complains of nausea and abdominal distention. The first action by the nurse should be to a. auscultate for hypotonic bowel sounds. b. notify the patients health care provider. c. reposition the tube and check for placement. d. remove the tube and replace it with a new one.

ANS: C Repositioning the tube will frequently facilitate drainage. Because this is a common occurrence, it is not appropriate to notify the health care provider unless other interventions do not resolve the problem. Information about the presence or absence of bowel sounds will not be helpful in improving drainage. Removing the tube and replacing it are unnecessarily traumatic to the patient, so that would only be done if the tube was completely occluded. DIF: Cognitive Level: Apply (application) REF: 970 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A 73-year-old patient with diverticulosis has a large bowel obstruction. The nurse will monitor for a. referred back pain. b. metabolic alkalosis. c. projectile vomiting. d. abdominal distention.

ANS: D Abdominal distention is seen in lower intestinal obstruction. Referred back pain is not a common clinical manifestation of intestinal obstruction. Metabolic alkalosis is common in high intestinal obstruction because of the loss of HCl acid from vomiting. Projectile vomiting is associated with higher intestinal obstruction. DIF: Cognitive Level: Apply (application) REF: 983 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

Which question from the nurse would help determine if a patients abdominal pain might indicate irritable bowel syndrome? a. Have you been passing a lot of gas? b. What foods affect your bowel patterns? c. Do you have any abdominal distention? d. How long have you had abdominal pain?

ANS: D One criterion for the diagnosis of irritable bowel syndrome (IBS) is the presence of abdominal discomfort or pain for at least 3 months. Abdominal distention, flatulence, and food intolerance are also associated with IBS, but are not diagnostic criteria. DIF: Cognitive Level: Apply (application) REF: 972 | eTable 43-3 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

Which patient should the nurse assess first after receiving change-of-shift report? a. 60-year-old patient whose new ileostomy has drained 800 mL over the previous 8 hours b. 50-year-old patient with familial adenomatous polyposis who has occult blood in the stool c. 40-year-old patient with ulcerative colitis who has had six liquid stools in the previous 4 hours d. 30-year-old patient who has abdominal distention and an apical heart rate of 136 beats/minute

ANS: D The patients abdominal distention and tachycardia suggest hypovolemic shock caused by problems such as peritonitis or intestinal obstruction, which will require rapid intervention. The other patients should also be assessed as quickly as possible, but the data do not indicate any life-threatening complications associated with their diagnoses. DIF: Cognitive Level: Analyze (analysis) REF: 974 OBJ: Special Questions: Prioritization; Multiple Patients TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment

A 45-year-old patient is admitted to the emergency department with severe abdominal pain and rebound tenderness. Vital signs include temperature 102 F (38.3 C), pulse 120, respirations 32, and blood pressure (BP) 82/54. Which prescribed intervention should the nurse implement first? a. Administer IV ketorolac (Toradol) 15 mg. b. Draw blood for a complete blood count (CBC). c. Obtain a computed tomography (CT) scan of the abdomen. d. Infuse 1 liter of lactated Ringers solution over 30 minutes.

ANS: D The priority for this patient is to treat the patients hypovolemic shock with fluid infusion. The other actions should be implemented after starting the fluid infusion. DIF: Cognitive Level: Apply (application) REF: 973 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity