Acute Final MC Ques- PART 3

A male client with a long history of ulcerative colitis experienced massive bleeding and had emergency surgery for creation of an ileostomy. He is very concerned that sexual intercourse with his wife will be impossible because of his new ileostomy pouch. How does the nurse respond? A. "A change in position may be what is needed for you to have intercourse with your wife." B. "Have you considered going to see a marriage counselor with your wife?" C. "What has your wife said about your pouch system?" D. "You must get clearance from your health care provider before you attempt to have intercourse."

"A change in position may be what is needed for you to have intercourse with your wife." A simple change in positioning during intercourse may alleviate the client's apprehension and facilitate sexual relations with his wife. Suggesting marriage counseling may address the client's concerns, but it focuses on the wrong issue; the client has not stated that he has relationship problems. Asking the client what his wife has said about the pouch may address the client's concerns, but it similarly focuses on the wrong issue. Telling the client that he needs to get clearance from his health care provider is an evasive response that does not address the client's primary concern.

A nurse is teaching a client with Crohn's disease about managing the disease with the drug adalimumab (Humira). Which instruction does the nurse emphasize to the client? A. "Avoid large crowds and anyone who is sick." B. "Do not take the medication if you are allergic to foods with fatty acids." C. "Expect difficulty with wound healing while you are taking this drug." D. "Monitor your blood pressure and report any significant decrease in it."

"Avoid large crowds and anyone who is sick." The client should avoid being around large crowds to prevent developing an infection. The client should not take the medication if he or she is allergic to certain proteins. Although immune suppression may occur to some degree, the client should not experience difficulty with wound healing while taking adalimumab. The client should not experience a decrease in blood pressure from taking this drug.

A client diagnosed with ulcerative colitis is to be discharged on loperamide (Imodium) for symptomatic management of diarrhea. What does the nurse include in the teaching about this medication? A. "Be aware of the symptoms of toxic megacolon that we discussed." B. "If diarrhea increases, you should let your health care provider know." C. "Pregnancy should be avoided." D. "You will need to decrease your dose of sulfasalazine (Azulfidine)."

"Be aware of the symptoms of toxic megacolon that we discussed." Antidiarrheal drugs may precipitate colonic dilation and toxic megacolon. Toxic megacolon is characterized by an enlarged colon with fever, leukocytosis, and tachycardia. Loperamide will decrease diarrhea rather than increase it. Constipation is sometimes a problem. No contraindication for pregnancy is noted. Sulfasalazine therapy typically continues on a long-term basis.

A certified Wound, Ostomy, and Continence Nurse is teaching a client about caring for a new ileostomy. What information is most important to include? A. "After surgery, output from your ileostomy may be a loose, dark-green liquid with some blood present." B. "Call the health care provider if your stoma has a bluish or pale look." C. "Notify the health care provider if output from your stoma has a sweetish odor." D. "Remember that you must wear a pouch system at all times."

"Call the health care provider if your stoma has a bluish or pale look." If the stoma has a bluish, pale, or dark look, its blood supply may be compromised and the health care provider must be notified immediately. It is true that output from the stoma after surgery may be a loose, greenish-colored liquid that may contain some blood, but this information is not the highest priority for instruction. It is normal for output from the stoma to have very little odor or a sweetish smell. Although it is true that the client will be required to wear a pouch system at all times, this is not the highest priority for instruction.

A nurse is teaching a client about dietary methods to help manage exacerbations ("flare-ups") of diverticulitis. What does the nurse advise the client? A. "Be sure to maintain an exclusively low-fiber diet to prevent pain on defecation." B. "Consume a low-fiber diet while your diverticulitis is active. When inflammation resolves, consume a high-fiber diet." C. "Maintain a high-fiber diet to prevent the development of hemorrhoids that frequently accompany this condition." D. "Make sure you consume a high-fiber diet while diverticulitis is active. When inflammation resolves, consume a low-fiber diet."

"Consume a low-fiber diet while your diverticulitis is active. When inflammation resolves, consume a high-fiber diet." The most effective way to manage diverticulitis is with a low-fiber diet while inflammation is present, followed by a high-fiber diet once the inflammation has subsided. Neither an exclusively low-fiber diet or an exclusively high-fiber diet will effectively manage diverticulitis. A high-fiber diet while diverticulitis is active will only worsen the disease and its symptoms.

A client who developed viral gastroenteritis with vomiting and diarrhea is scheduled to be seen in the clinic the following day. What will the nurse teach the client to do in the meantime? A. "Avoid all solid foods to allow complete bowel rest." B. "Consume extra fluids to replace fluid losses." C. "Take an over-the-counter antidiarrheal medication." D. "Contact your provider for an antibiotic medication."

"Consume extra fluids to replace fluid losses." Clients should be taught to drink extra fluids to replace fluid lost through vomiting and diarrhea. It is not necessary to stop all solid food intake. Antidiarrheal medications are used if diarrhea is severe. Antibiotics are used if the infection is bacterial.

The nurse is caring for a client who is to be discharged after a bowel resection and the creation of a colostomy. Which client statement demonstrates that additional instruction from the nurse is needed? A. "I can drive my car in about 2 weeks." B. "I should avoid drinking carbonated sodas." C. "It may take 6 weeks to see the effects of some foods on my bowel patterns." D. "Stool softeners will help me avoid straining."

"I can drive my car in about 2 weeks." The client who has had a bowel resection and colostomy should avoid driving for 4 to 6 weeks. The client should avoid drinking sodas and other carbonated drinks because of the gas they produce. He or she may not be able to see the effects of certain foods on bowel patterns for several weeks. The client should avoid straining at stool.

The home health nurse is teaching a client about the care of a new colostomy. Which client statement demonstrates a correct understanding of the instructions? A. "A dark or purplish-looking stoma is normal and should not concern me." B. "If the skin around the stoma is red or scratched, it will heal soon." C. "I need to check for leakage underneath my colostomy." D. "I should strive for a very tight fit when applying the barrier around the stoma."

"I need to check for leakage underneath my colostomy." The pouch system should be checked frequently for evidence of leakage to prevent excoriation. A purplish stoma is indicative of ischemia and necrosis. Redness or scratched skin around the stoma should be reported to prevent it from beginning to break down. An overly tight fit may lead to necrosis of the stoma.

A client with irritable bowel syndrome (IBS) is constipated. The nurse instructs the client about a management plan. Which client statement shows an accurate understanding of the nurse's teaching? A. "A drink of diet soda with dinner is OK for me." B. "I need to go for a walk every evening." C. "Maintaining a low-fiber diet will manage my constipation." D. "Watching the amount of fluid that I drink with meals is very important."

"I need to go for a walk every evening." Increased ambulation is part of the management plan for IBS, along with increased fluids and fiber and avoiding caffeinated beverages. Caffeinated beverages can cause bloating or diarrhea and should be avoided in clients with IBS. Fiber is encouraged in clients with IBS because it produces a bulky soft stool and aids in establishing regular bowel habits. At least 8 to 10 cups of fluid should be consumed daily to promote normal bowel function.

The Certified Wound, Ostomy, and Continence Nurse is teaching a client with colorectal cancer how to care for a newly created colostomy. Which client statement reflects a correct understanding of the necessary self-management skills? A. "I will have my spouse change the bag for me." B. "If I have any leakage, I'll put a towel over it." C. "I need to call my home health nurse to come out if I have any problems." D. "I will make certain that I always have an extra bag available."

"I will make certain that I always have an extra bag available." The statement that the client will be certain to bring an extra bag is the only statement illustrating that the client is taking responsibility to care for the colostomy. Using a towel is not an acceptable or effective way to cope with leakage. It is not realistic that the home health nurse can make frequent visits for the purpose of colostomy care.

The nurse is teaching a client who has undergone a hemorrhoidectomy about a follow-up plan of care. Which client statement demonstrates a correct understanding of the nurse's instructions? A. "I should take Ex-Lax after the surgery to 'keep things moving'." B. "I will need to eat a diet high in fiber." C. "Limiting my fluids will help me with constipation." D. "To help with the pain, I'll apply ice to the surgical area."

"I will need to eat a diet high in fiber." A diet high in fiber serves as a natural stool softener and will prevent irritation to hemorrhoids caused by painful bowel movements. Stimulant laxatives are discouraged because they are habit-forming. Increased amounts of fluids are needed to prevent constipation. Moist heat (sitz baths) will be more effective with postoperative discomfort than cold applications; cold therapy is sometimes recommended and useful before surgery for inflamed hemorrhoids.

A 24-year-old male is scheduled for a minimally invasive inguinal hernia repair (MIIHR). Which client statement indicates a need for further teaching about this procedure? A. "I may have trouble urinating immediately after the surgery." B. "I will need to stay in the hospital overnight." C. "I should not eat after midnight the day of the surgery." D. "My chances of having complications after this procedure are slim."

"I will need to stay in the hospital overnight." Usually, the client is discharged 3 to 5 hours after MIIHR surgery. Male clients who have difficulty urinating after the procedure should be encouraged to force fluids and to assume a natural position when voiding. Clients undergoing MIIHR surgery must be NPO after midnight before the surgery. Most clients who have MIIHR surgery have an uneventful recovery.

A client suspected of having irritable bowel syndrome (IBS) is scheduled for a hydrogen breath test. What does the nurse tell the client about this test? A. "During the test, you will drink small amounts of an antacid as directed by the technician." B. "If you have IBS, hydrogen levels may be increased in your breath samples." C. "The test will take between 30 and 45 minutes to complete." D. "You must have nothing to drink (except water) for 24 hours before the test."

"If you have IBS, hydrogen levels may be increased in your breath samples." Excess hydrogen levels are produced in clients with IBS. This is due to bacterial overgrowth in the small intestine that accompanies the disease. The hydrogen travels to the lungs to be excreted. The client will ingest small amounts of sugar during the test, not an antacid. The test takes longer than 45 minutes. The client has breath samples taken every 15 minutes for 1 to 2 hours. The client needs to be NPO (except for water) for 12 hours before the test.

A client with an exacerbation of ulcerative colitis has been prescribed Vivonex PLUS. The client asks the nurse how this is helpful for improving symptoms. How does the nurse reply? A. "It is absorbed quickly and allows the affected part of the GI tract to rest and heal." B. "It provides key nutrients and extra calories to promote healing." C. "It is bland and reduces the secretion of gastric acids." D. "It does not contain caffeine or other GI tract stimulants."

"It is absorbed quickly and allows the affected part of the GI tract to rest and heal." For less severe exacerbations, an elemental or semi-elemental product such as Vivonex PLUS may be prescribed to induce remission. These products are absorbed in the jejunum and therefore permit the distal small intestine and colon to rest. Nutritional supplements such as Ensure or Sustacal are added to provide nutrients and more calories. GI stimulants such as caffeinated beverages and alcohol should be avoided, but this is not the reason for using Vivonex PLUS.

A client has been newly diagnosed with ulcerative colitis (UC). What does the nurse teach the client about diet and lifestyle choices? A. "Drinking carbonated beverages will help with your abdominal distress." B. "It's OK to smoke cigarettes, but you should limit them to ½ pack per day." C. "Lactose-containing foods should be reduced or eliminated from your diet." D. "Raw vegetables and high-fiber foods may help to diminish your symptoms."

"Lactose-containing foods should be reduced or eliminated from your diet." Lactose-containing foods are often poorly tolerated and should be reduced or eliminated from the diet of clients with UC. Carbonated beverages are GI stimulants that can cause discomfort and should be used rarely or completely eliminated from the diet. Cigarette smoking is a stimulant that can cause GI distress symptoms; nurses should never advise clients that any amount of cigarette smoking is "OK." Raw vegetables and high-fiber foods can cause GI symptoms in clients with UC.

A client with malabsorption syndrome asks the nurse, "What did I do to cause this disorder to develop?" How does the nurse respond? A. "An excessive intake of alcohol is associated with it, so your substance abuse could have contributed to its development." B. "It is inherited, so it could run in your family." C. "It might be caused by a virus, so you could have gotten it almost anywhere." D. "Nothing you did could have caused it; it is the result of flattening of the mucosa of your large intestine."

"Nothing you did could have caused it; it is the result of flattening of the mucosa of your large intestine." Stating that the disorder is the result of flattening of the mucosa of the large intestine is the only statement that is physiologically accurate. Malabsorption syndrome is not associated with an excessive intake of alcohol. It is not inherited, although a genetic immune defect is present in the related disease, celiac sprue. It is not caused by a virus.

A client with colorectal cancer is scheduled for colostomy surgery. Which comment from the nurse is most therapeutic for this client? A. "Are you afraid of what your spouse will think of the colostomy?" B. "Don't worry. You will get used to the colostomy eventually." C. "Tell me what worries you the most about this procedure." D. "Why are you so afraid of having this procedure done?"

"Tell me what worries you the most about this procedure." Asking the client about what worries him or her is the only question that allows the client to express fears and anxieties about the diagnosis and treatment. Asking the client if he or she is afraid is a closed question (i.e., it requires only a "yes" or "no" response); it closes the dialogue and is not therapeutic. Telling the client not to worry offers reassurance and is a "pat" statement, making it nontherapeutic. "Why" questions place clients on the defense and are not therapeutic because they close the conversation.

A male client's sister was recently diagnosed with colorectal cancer (CRC), and his brother died of CRC 5 years ago. He asks the nurse whether he will inherit the disease too. How does the nurse respond? A. "Have you asked your health care provider what he or she thinks your chances are?" B. "It is hard to know what can predispose a person to develop a certain disease." C. "No. Just because they both had CRC doesn't mean that you will have it, too." D. "The only way to know whether you are predisposed to CRC is by genetic testing."

"The only way to know whether you are predisposed to CRC is by genetic testing." Genetic testing is the only definitive way to determine whether the client has a predisposition to develop CRC. A higher incidence of the disease has been noted in families who have a history; however, it is not the responsibility of the nurse to engage in genetic counseling, and this client might not be predisposed to developing CRC. Asking the client what the health care provider thinks is an evasive response by the nurse and does not address the client's concerns.

A client is admitted with severe viral gastroenteritis caused by norovirus. The client asks the nurse, "How did I get this disease?" Which answer by the nurse is correct? A. "You may have contracted it from an infected infant." B. "You may have consumed contaminated food or water." C. "You may have come into contact with an infected animal." D. "You may have had contact with the blood of an infected person."

"You may have consumed contaminated food or water." Norovirus is the leading foodborne disease that causes gastroenteritis. It is transmitted via the fecal-oral route from person to person and from contaminated food and water. Vomiting causes the virus to become airborne. Campylobacter can be transmitted by contact with infected infants or animals. Escherichia coli may be spread via animals and contaminated food, water, or fomites. HIV may be spread via the blood, but not norovirus. Campylobacter and E. coli both cause bacterial gastroenteritis, while norovirus causes viral gastroenteritis.

A client newly diagnosed with ulcerative colitis (UC) is started on sulfasalazine (Azulfidine). What does the nurse tell the client about why this therapy has been prescribed? A. "It is to stop the diarrhea and bloody stools." B. "This will minimize your GI discomfort." C. "With this medication, your cramping will be relieved." D. "Your intestinal inflammation will be reduced."

"Your intestinal inflammation will be reduced." Sulfasalazine (Azulfidine) is one of the primary treatments for UC. It is thought to inhibit prostaglandin synthesis and thereby reduce inflammation. Although it is hoped that reduction of inflammation will cause the diarrhea and bloody stools to stop, this is not the way that the drug works. Antidiarrheal drugs "stop" diarrhea. The drug's action as an anti-inflammatory will diminish the client's pain as the inflammation subsides, but this is not the purpose of the drug—it is not an analgesic.

The RN receives a change-of-shift report about four clients. Which client does the nurse assess first? A. A 20-year-old with ulcerative colitis (UC) who had six liquid stools during the previous shift B. A 25-year-old who has just been admitted with possible appendicitis and has a temperature of 102° F C. A 56-year-old who had a colon resection earlier in the day and whose colostomy bag does not have any stool in it D. A 60-year-old admitted with acute gastroenteritis who is reporting severe cramping and nausea

A 25-year-old who has just been admitted with possible appendicitis and has a temperature of 102° F This client with possible appendicitis may have developed a perforation and may be at risk for peritonitis. Rapid assessment and possible surgical intervention are needed. The client with UC who had six liquid stools, the client whose colostomy bag does not have any stool in it, and the client who was admitted with acute gastroenteritis all need assessment and intervention by an RN, but they are not at immediate risk for life-threatening complications. The client with possible appendicitis has a life-threatening emergency.

Which client does the charge nurse assign to an experienced LPN/LVN? A. A 28-year-old who requires teaching about how to catheterize a Kock ileostomy B. A 30-year-old who must receive neomycin sulfate (Mycifradin) before a colectomy C. A 34-year-old with ulcerative colitis (UC) who has a white blood cell count of 23,000/mm3 D. A 38-year-old with gastroenteritis who is receiving IV fluids at 250 mL/hr

A 30-year-old who must receive neomycin sulfate (Mycifradin) before a colectomy The LPN/LVN should be familiar with the purpose, adverse effects, and client teaching required for neomycin. Teaching about how to catheterize a Kock ileostomy, assessing the client with UC with a high white blood cell count, and monitoring the client with gastroenteritis receiving IV fluids present complex problems that require assessment or intervention by an RN.

The RN on the medical-surgical unit receives a shift report about four clients. Which client does the nurse assess first? A. A 34-year-old who has returned to the unit after a colon resection with a new colostomy stoma, which is dark pink B. A 36-year-old admitted after a motor vehicle crash with areas of ecchymoses on the abdomen in a "lap-belt" pattern C. A 40-year-old with pneumonia who has abdominal distention and decreased bowel sounds in all quadrants D. A 51-year-old with familial adenomatous polyposis (FAP) who is scheduled for a colonoscopy

A 36-year-old admitted after a motor vehicle crash with areas of ecchymoses on the abdomen in a "lap-belt" pattern Ecchymoses in the abdominal area may indicate intraperitoneal or intra-abdominal bleeding; this client requires rapid assessment and interventions. The client who is post colon resection, the client with pneumonia, and the client with FAP do not have an urgent need for further assessment or intervention.

An intensive care unit (ICU) RN is "floated" to the medical-surgical unit. Which client does the charge nurse assign to the float nurse? A. A 28-year-old with an exacerbation of Crohn's disease (CD) who has a draining enterocutaneous fistula B. A 32-year-old with ulcerative colitis (UC) who needs discharge teaching about the use of hydrocortisone enemas C. A 34-year-old who has questions about how to care for a newly created ileo-anal reservoir D. A 36-year-old with peritonitis who just returned from surgery with multiple drains in place

A 36-year-old with peritonitis who just returned from surgery with multiple drains in place The ICU nurse is familiar with the care of a client with peritonitis, including monitoring for complications such as sepsis and kidney failure. The client with CD who has a draining enterocutaneous fistula, the client with UC who needs discharge teaching, and the client with questions about an ileo-anal reservoir are best assigned to a medical-surgical nurse who is more familiar with the care and teaching needed for clients with their respective disorders.

Which client does the medical-surgical unit charge nurse assign to an LPN/LVN? A. A 41-year-old who needs assistance with choosing a site for a colostomy stoma B. A 47-year-old who needs to receive "whole gut" lavage before a colon resection C. A 51-year-old who has recently arrived on the unit after having an open herniorrhaphy D. A 56-year-old who has obstipation and a recent emesis of foul-smelling liquid

A 47-year-old who needs to receive "whole gut" lavage before a colon resection Because administration of medications is within the LPN/LVN scope of practice, this preoperative client can be assigned to the LPN/LVN. Assistance with choosing a site for a colostomy stoma is an intervention that should be provided by an RN. The recent postoperative client and the critically ill client will need assessments and interventions that can only be done by an RN.

The nurse is instructing a client with recently diagnosed diverticular disease about diet. What food does the nurse suggest the client include? A. A slice of 5-grain bread B. Chuck steak patty (6 ounces) C. Strawberries (1 cup) D. Tomato (1 medium)

A slice of 5-grain bread Whole-grain breads are recommended to be included in the diet of clients with diverticular disease because cellulose and hemicellulose types of fiber are found in them. Dietary fat should be reduced in clients with diverticular disease. If the client wants to eat beef, it should be of a leaner cut. Foods containing seeds, such as strawberries, should be avoided. Tomatoes should be avoided unless the seeds are removed. The seeds may block diverticula in the client and present problems leading to diverticulitis.

The nurse is teaching a group of clients with irritable bowel syndrome (IBS) about complementary and alternative therapies. What does the nurse suggest as possible treatment modalities? (Select all that apply.) A. Acupuncture B. Decreasing physical activities C. Herbs (moxibustion) D. Meditation E. Peppermint oil capsules F. Yoga

A. Acupuncture C. Herbs (moxibustion) D. Meditation E. Peppermint oil capsules F. Yoga Acupuncture is recommended as a complementary therapy for IBS. Moxibustion is helpful for some clients with IBS. Meditation, yoga, and other relaxation techniques help many clients manage stress and their IBS symptoms. Research has shown that peppermint oil capsules may be effective in reducing symptoms of IBS. Regular exercise is important for managing stress and promoting bowel elimination.

The nurse is teaching a client who recently began taking sulfasalazine (Azulfidine) about the drug. What side effects does the nurse tell the client to report to the health care provider? (Select all that apply.) A. Anorexia B. Depression C. Drowsiness D. Frequent urination E. Headache F. Vomiting

A. Anorexia E. Headache F. Vomiting Anorexia, headache, and nausea/vomiting are side effects of sulfasalazine that should be reported to the health care provider. Depression, drowsiness, and urinary problems are not side effects of sulfasalazine.

The nurse is teaching a client with a newly created colostomy about foods to limit or avoid because of flatulence or odors. Which foods are included? (Select all that apply.) A. Broccoli B. Buttermilk C. Mushrooms D. Onions E. Peas F. Yogurt

A. Broccoli C. Mushrooms D. Onions E. Peas Broccoli, mushrooms, onions, and peas often cause flatus. Buttermilk will help prevent odors. Yogurt can help prevent flatus.

A client is scheduled for discharge after surgery for inflammatory bowel disease. The client's spouse will be assisting home health services with the client's care. What is most important for the home health nurse to assess in the client and the spouse with regard to the client's home care? A. Ability of the client and spouse to perform incision care and dressing changes B. Effective coping mechanisms for the client and spouse after the surgical experience C. Knowledge about the client's requested pain medications D. Understanding of the importance of keeping scheduled follow-up appointments

Ability of the client and spouse to perform incision care and dressing changes Assessing the client's and the spouse's ability to carry out incision care and dressing changes is essential for avoiding further development of the infectious process, as well as infection of the surgical incision itself. Assessing coping mechanisms and knowledge of the client's pain medication are important, but are not the priority. Understanding the importance of scheduled follow-up appointments is important, but is not the priority.

Aside from chemotherapeutic agents, what other medications does the nurse expect to administer to a client with advanced colorectal cancer for relief of symptoms? A. Analgesics and antiemetics B. Analgesics and benzodiazepines C. Steroids and analgesics D. Steroids and anti-inflammatory medications

Analgesics and antiemetics Clients with advanced colorectal cancer and metastasis also receive drugs such as analgesics and antiemetics for relief of symptoms, specifically pain and nausea. Benzodiazepines, steroids, and anti-inflammatory medications are not routinely requested for these clients.

A male client in a long-term care facility is 2 days postoperative after an open repair of an indirect inguinal hernia. Which nursing action does the RN delegate to unlicensed assistive personnel (UAP)? A. Assessing the client's incision for signs of infection B. Assisting the client to stand to void C. Instructing the client in how to deep-breathe D. Monitoring the client's pain level

Assisting the client to stand to void Assisting the client with activities is part of the UAP role. Assessment of the client's incision and pain level requires broader education and scope of practice and should be done by licensed nursing personnel. Client teaching—even about something as fundamental as taking "deep breaths"—likewise requires broader education and scope of practice and should be done by licensed nursing personnel.

A client is diagnosed with irritable bowel syndrome (IBS). What factors does the nurse suspect as possible causes of the client's problem? (Select all that apply.) A. Antihistamines B. Caffeinated drinks C. Stress D. Sleeping pills E. Anxiety

B. Caffeinated drinks C. Stress E. Anxiety Factors such as ingestion of coffee or other gastric stimulants, stress, anxiety, and milk allergy are being investigated as possible causes of IBS. Antihistamines and sleeping pills are not suspected as causing IBS.

What does the nurse advise a client diagnosed with irritable bowel syndrome (IBS) to take during periods of constipation? A. Bulk-forming laxatives B. Saline laxatives C. Stimulant laxatives D. Stool-softening agents

Bulk-forming laxatives For treatment of constipation-predominant IBS, bulk-forming laxatives are generally taken at mealtimes with a glass of water. Saline and stimulant laxatives are not used for the treatment of constipation-predominant IBS. Stool-softening agents are not effective.

A client returns to the unit after having an exploratory abdominal laparotomy. How does the nurse position this client after the client is situated in bed? A. High Fowler's B. Lateral Sims' (side-lying) C. Semi-Fowler's D. Supine

C. Semi-Fowler's

The nurse case manager is discussing community resources with a client who has colorectal cancer and is scheduled for a colostomy. Which referral is of greatest value to this client initially? A. Certified Wound, Ostomy, and Continence Nurse (CWOCN) B. Home health nursing agency C. Hospice D. Hospital chaplain

Certified Wound, Ostomy, and Continence Nurse (CWOCN) A CWOCN (or an enterostomal therapist) will be of greatest value to the client because the client is scheduled to receive a colostomy. The client is newly diagnosed, so it is not yet known whether home health nursing will be needed. A referral to hospice may be helpful for a terminally ill client. Referral to a chaplain may be helpful later in the process of adjusting to the disease.

A home health client has had severe diarrhea for the past 24 hours. Which nursing action does the RN delegate to the home health aide (unlicensed assistive personnel [UAP]) who assists the client with self-care? A. Instructing the client about the use of electrolyte-containing oral rehydration products B. Administering loperamide (Imodium) 4 mg from the client's medicine cabinet C. Checking and reporting the client's heart rate and blood pressure in lying, sitting, and standing positions D. Teaching the client how to clean the perineal area after each loose stool

Checking and reporting the client's heart rate and blood pressure in lying, sitting, and standing positions Obtaining the client's blood pressure and heart rate is included in the education of home health aides and other UAP. Client teaching and medication administration are complex skills that should be performed by licensed nurses who have the education and scope of practice needed to safely implement these actions.

A client has vague symptoms that indicate an acute inflammatory bowel disorder. Which symptom is most indicative of Crohn's disease (CD)? A. Abdominal pain relieved by bending the knees B. Chronic diarrhea, abdominal pain, and fever C. Epigastric cramping D. Hypotension with vomiting

Chronic diarrhea, abdominal pain, and fever Chronic diarrhea, abdominal pain, and fever are symptoms more indicative of CD than of other acute inflammatory bowel disorders. Abdominal pain that is relieved by bending the knees is indicative of peritonitis or pancreatitis. Epigastric cramping is a symptom more indicative of appendicitis. Hypotension with vomiting is not characteristic of CD.

Which is a correct statement differentiating Crohn's disease (CD) from ulcerative colitis (UC)? A. Clients with CD experience about 20 loose, bloody stools daily. B. Clients with UC may experience hemorrhage. C. The peak incidence of UC is between 15 and 40 years of age. D. Very few complications are associated with CD.

Clients with UC may experience hemorrhage. Hemorrhage is commonly experienced by clients with UC. Five to six stools daily is common with CD. The peak incidences of UC are between 15 to 25 and 55 to 65 years of age. Fistulas commonly occur as a complication of CD.

A client with a bowel obstruction is ordered a nasogastric (NG) tube. After the nurse inserts the tube, which nursing intervention is the highest priority for this client? A. Attaching the tube to high continuous suction B. Auscultating for bowel sounds and peristalsis while the suction runs C. Connecting the tube to low intermittent suction D. Flushing the tube with 30 mL of normal saline every 24 hours

Connecting the tube to low intermittent suction The NG tube should be attached to intermittent low suction unless otherwise requested by the health care provider. Continuous suction is rarely used because it can injure the gastric mucosa of the client's stomach. Bowel sounds should not be auscultated with suction on and running. The tube should be flushed every 4 hours, minimally.

A client with ulcerative colitis is prescribed sulfasalazine (Azulfidine) and corticosteroid therapy. As the disease improves, what change does the nurse expect in the client's medication regimen? A. Corticosteroid therapy will be stopped. B. Sulfasalazine (Azulfidine) will be stopped. C. Corticosteroid therapy will be tapered. D. Sulfasalazine (Azulfidine) will be tapered.

Corticosteroid therapy will be tapered. Once clinical improvement has been established, corticosteroids are tapered over a 2- to 3-month period. Stopping corticosteroid therapy abruptly is unsafe—steroids must be gradually decreased in clients. Usually the amount that they have been taking dictates how quickly or slowly they can be stopped. Sulfasalazine therapy will be taken on a long-term basis. It may be increased or decreased, depending on the client's symptoms, but will likely never be stopped. These decisions are made over a long period of therapy.

A client with a family history of colorectal cancer (CRC) regularly sees a health care provider for early detection of any signs of cancer. Which laboratory result may be an indication of CRC in this client? A. Decrease in liver function test results B. Elevated carcinoembryonic antigen C. Elevated hemoglobin levels D. Negative test for occult blood

Elevated carcinoembryonic antigen Carcinoembryonic antigen may be elevated in many clients diagnosed with CRC. Liver involvement may or may not occur in CRC. Hemoglobin will likely be decreased with CRC, not increased. An occult blood test is not reliable to affirm or rule out CRC.

A client with colorectal cancer had colostomy surgery performed yesterday. The client is very anxious about caring for the colostomy and states that the health care provider's instructions "seem overwhelming." What does the nurse do first for this client? A. Encourages the client to look at and touch the colostomy stoma B. Instructs the client about complete care of the colostomy C. Schedules a visit from a client who has a colostomy and is successfully caring for it D. Suggests that the client involve family members in the care of the colostomy

Encourages the client to look at and touch the colostomy stoma The initial intervention is to get the client comfortable looking at and touching the stoma before providing instructions on its care. Instructing the client about colostomy care will be much more effective after the client's anxiety level has stabilized. Talking with someone who has gone through a similar experience may be helpful to the client only after his or her anxiety level has stabilized. The client has begun to express feelings regarding the colostomy and its care; it is too soon to involve others. The client must get comfortable with this body image change first.

A client with colorectal cancer was started on 5-fluorouracil (5-FU) and is experiencing fatigue, diarrhea, and mouth ulcers. A relatively new chemotherapeutic agent, oxaliplatin (Eloxatin), has been added to the treatment regimen. What does the nurse tell the client about the diarrhea and mouth ulcers? A. "A combination of chemotherapeutic agents has caused them." B. "GI problems are symptoms of the advanced stage of your disease." C. "5-FU cannot discriminate between your cancer and your healthy cells." D. "You have these as a result of the radiation treatment."

"5-FU cannot discriminate between your cancer and your healthy cells." 5-FU cannot discriminate between cancer and healthy cells; therefore, the side effects are diarrhea, mucositis, leukopenia, mouth ulcers, and skin ulcers. The 5-FU treatment, not a combination of chemotherapy drugs, radiation, or the stage of the disease, is what is causing the client's GI problems.

A client with a recent surgically created ileostomy refuses to look at the stoma and asks the nurse to perform all required stoma care. What does the nurse do next? A. Asks the client whether family members could be trained in stoma care B. Has another client with a stoma who performs self-care talk with the client C. Requests that the health care provider request antidepressants and a psychiatric consult D. Suggests that the health care provider request a home health consultation so stoma care can be performed by a home health nurse

Has another client with a stoma who performs self-care talk with the client Talking with another client who successfully cares for his or her stoma may give the client the confidence to begin his or her self-care. If at all possible, the client should perform stoma care so that he or she can be as independent as possible. Although the client may need medication for depression, the priority is to encourage the client to look at, touch, and begin caring for the stoma. A home health nurse can be a support, but cannot provide all of the care that the client will need.

A client with a history of osteoarthritis has a 10-inch incision following a colon resection. The incision has become infected, and the wound requires extensive irrigation and packing. What aspect of the client's care does the nurse make certain to discuss with the health care provider before the client's discharge? A. Having a home health consultation for wound care B. Requesting an anti-anxiety medication C. Requesting pain medication for the client's osteoarthritis D. Placing the client in a skilled nursing facility for rehabilitation

Having a home health consultation for wound care Home health services are most appropriate for this client because wound care will be extensive and the client's mobility may be limited. No indication suggests that the client is experiencing anxiety regarding postoperative care. Pain medication may be needed for the client's osteoarthritis, but this is not the highest priority. A skilled nursing facility is not necessary if the client can remain in his or her home with sufficient support services.

A client has developed gastroenteritis while traveling outside the country. What is the likely cause of the client's symptoms? A. Bacteria on the client's hands B. Ingestion of parasites in the water C. Insufficient vaccinations D. Overcooked food

Ingestion of parasites in the water A main cause of gastroenteritis when traveling outside the country is ingestion of water that is infested with parasites. Bacteria on the client's hands will not produce gastroenteritis unless food or water is contaminated with the bacteria. Insufficient vaccinations may cause other disease processes, but not gastroenteritis. Undercooked, not overcooked, food may produce gastroenteritis.

.What is the mechanism of action for the chemotherapeutic drug cetuximab (Erbitux)? A. It destroys the cancer's cell wall, which will kill the cell. B. It decreases blood flow to rapidly dividing cancer cells. C. It stimulates the body's immune system and stunts cancer growth. D. It blocks factors that promote cancer cell growth.

It blocks factors that promote cancer cell growth. Cetuximab, a monoclonal antibody, may be given for advanced disease. This drug works by binding to a protein (epidermal growth factor receptor) to slow cell growth. The medication does not destroy the cancer's cell walls and does not stimulate the body's immune system or stunt cancer growth in that manner. The treatment does not decrease blood flow to rapidly dividing cancer cells.

A client admitted with severe gastroenteritis has been started on an IV, but the client continues having excessive diarrhea. Which medication does the nurse ask the health care provider about prescribing? A. Balsalazide (Colazal) B. Loperamide (Imodium) C. Mesalamine (Asacol) D. Milk of Magnesia (MOM)

Loperamide (Imodium) If the health care provider determines that antiperistaltic agents are necessary, an initial dose of loperamide (Imodium) 4 mg can be administered orally, followed by 2 mg after each loose stool, up to 16 mg daily. Balsalazide is not the best choice for control of diarrhea in this scenario. Mesalamine is used for clients with ulcerative colitis for long-term therapy. MOM is a laxative.

A client diagnosed with irritable bowel syndrome (IBS) is discharged home with a variety of medications for IBS symptoms. Upon returning to the clinic, the client states, "Most of my symptoms have improved, except for the diarrhea." What does the nurse anticipate will be prescribed for this client? A. Antidiarrheal agent B. Muscarinic receptor antagonist C. Serotonin antagonist D. Tricyclic antidepressant

Muscarinic receptor antagonist A muscarinic (M3) receptor antagonist can also inhibit intestinal motility. Antidiarrheal agents and serotonin antagonists are not the most effective choices for this client. A tricyclic antidepressant is not going to be effective for this client's diarrhea.

A client with an intestinal obstruction has pain that changes from a "colicky" intermittent type to constant discomfort. What does the nurse do first? A. Administers medication for pain B. Changes the nasogastric suction level from "intermittent" to "constant" C. Positions the client in high-Fowler's position D. Prepares the client for emergency surgery

Prepares the client for emergency surgery The change in pain type could be indicative of perforation or peritonitis and will require immediate surgical intervention. Pain medication may mask the client's symptoms but will not address the root cause. A change in the nasogastric suction rate will not resolve the cause of the client's pain and could be particularly ineffective if a nonvented tube is in use. A high-Fowler's position will have no effect on an intestinal perforation or peritonitis, which this client is likely experiencing.

A client demonstrates the manifestations of diverticulitis with a suspected complication of peritonitis. What is the priority nursing intervention? A. Assessing the client for changes in vital signs B. Medicating the client for pain C. Monitoring for changes in the client's mentation D. Preparing the client for emergency surgery

Preparing the client for emergency surgery The highest priority for this client is to prepare him or her for emergency surgery so that the source of the infection can be removed. It is expected that the client will experience changes in vital signs as a result of the infectious process and accompanying pain. Although monitoring the client's vital signs is important, the client has an immediate need to go to surgery. Medicating the client for pain and determining whether the client is experiencing changes in mentation are important, but are not the highest priority.

After an abdominoperineal resection, a 75-year-old client is referred to a home health agency. Which staff member does the nurse manager assign to perform the initial assessment on this client? A. LPN/LVN who has worked with many home health clients after colostomy surgeries B. LPN/LVN with 20 years of experience in the home health agency C. RN who is new to the agency with 5 years experience in the emergency department D. Social worker who is experienced with case management of older clients

RN who is new to the agency with 5 years experience in the emergency department Clients with medical or surgical diagnoses have complex physiologic needs that should be assessed by an RN. For this reason, Medicare requires that the initial assessment must be done by an RN, although LPN/LVNs and social workers are likely to be part of the health care team.

A 67-year-old male client reports pain in the inguinal area that occurs when he coughs. A bulge that can be pushed back into the abdomen is found in his inguinal area. What type of hernia does he have? A. Femoral B. Reducible C. Strangulated D. Ventral

Reducible The hernia is reducible because its contents can be pushed back into the abdominal cavity. Femoral hernias tend to occur more frequently in obese and pregnant women. A hernia is considered to be strangulated when the blood supply to the herniated segment of the bowel is cut off. It cannot be a ventral hernia because it would have to occur at the site of a previous surgical incision.

After an automobile crash, a client is admitted to the emergency department with possible abdominal trauma. Which health care provider request does the nurse implement first? A. Insert a nasogastric tube and connect it to intermittent suction. B. Obtain a complete blood count and coagulation panel. C. Start an IV line and infuse normal saline at 200 mL/hr. D. Arrange for a computed tomography (CT) scan of the abdomen.

Start an IV line and infuse normal saline at 200 mL/hr. After the initial airway, breathing, and circulation assessment is completed, the most immediate concerns are the high risks for hemorrhage and shock. To rapidly treat for these possible complications, IV access and infusion of fluids are necessary as the priority intervention. Inserting a nasogastric tube, laboratory studies, and arranging a CT scan are secondary to establishing IV access and instilling fluids.

An 80-year-old client with a 2-day history of myalgia, nausea, vomiting, and diarrhea is admitted to the medical-surgical unit with a diagnosis of gastroenteritis. Which health care provider request does the nurse implement first? A. Administer acetaminophen (Tylenol) 650 mg rectally. B. Draw blood for a complete blood count and serum electrolytes. C. Obtain a stool specimen for culture and sensitivity. D. Start an IV solution of 5% dextrose in 0.45 normal saline at 125 mL/hr.

Start an IV solution of 5% dextrose in 0.45 normal saline at 125 mL/hr. Fluid therapy is the focus of treatment for clients with gastroenteritis. Older clients are at increased risk for the complications of dehydration such as hypovolemia and acute kidney failure. Acetaminophen 650 mg should be rapidly administered rectally, and blood draws and stool specimen collection should be implemented rapidly, but prevention and treatment of dehydration are the priorities for this client.

An obese client is discharged 10 days after being hospitalized for peritonitis, which resulted in an exploratory laparotomy. Which assessment finding by the client's home health nurse requires immediate action? A. Pain when coughing B. States, "I am too tired to walk very much" C. States, "I feel like the incision is splitting open" D. Temperature of 100.8° F (38.2° C).

States, "I feel like the incision is splitting open" The client feeling like the incision is splitting open is at risk for poor wound healing and possible wound dehiscence; the nurse should immediately assess the wound and notify the health care provider. Reports of pain when coughing, being too tired to ambulate, and a temperature of 100.8° F (38.2° C) all require further assessment or intervention, but are not as great a concern as the possibility of wound dehiscence for this client.

A client asks the nurse, "Can you tell me some foods to include in my diet so that I can reduce my chances of getting colorectal cancer?" Which dietary selection does the nurse suggest? A. Steak with pasta B. Spaghetti with tomato sauce C. Steamed broccoli with turkey D. Tuna salad with wheat crackers

Steamed broccoli with turkey Steamed broccoli with turkey contains low-fat meat and no refined carbohydrates. Animal fat from red meats is carcinogenic, and pasta is high in refined carbohydrates, which are known to contribute to colon cancer. Spaghetti and wheat crackers also contain large amounts of refined carbohydrates.

A 21-year-old with a stab wound to the abdomen has come to the emergency department. Once stabilized, the client is admitted to the medical-surgical unit. What does the admitting nurse do first for this client? A. Administer pain medication. B. Assess skin temperature and color. C. Check on the amount of urine output. D. Take vital signs.

Take vital signs. Assessment of vital signs should be done first to determine the adequacy of the airway and circulation. Vital signs initially reveal the most about the client's condition. The client should not be medicated for pain until his or her alertness level is determined. Skin temperature and color are not specifically indicative of the client's overall condition. If the client is in shock, urine output will be scant and will not be an accurate assessment variable.

A client is being evaluated in the emergency department for a possible small bowel obstruction. Which signs and/or symptoms does the nurse expect to assess? A. Cramping intermittently, metabolic acidosis, and minimal vomiting B. Intermittent lower abdominal cramping, obstipation, and metabolic alkalosis C. Metabolic acidosis, upper abdominal distention, and intermittent cramping D. Upper abdominal distention, metabolic alkalosis, and great amount of vomiting

Upper abdominal distention, metabolic alkalosis, and great amount of vomiting A small bowel obstruction is characterized by upper or epigastric abdominal distention, metabolic alkalosis, and a great amount of vomiting. Intermittent lower abdominal cramping, metabolic acidosis, and minimal vomiting are all symptoms of a large bowel obstruction.

A client has an anal fissure. Which intervention most effectively promotes perineal comfort for the client? A. Administering a Fleet's enema when needed B. Applying heat to acute inflammation for pain relief C. Avoiding the use of bulk-forming agents D. Using hydrocortisone cream to relieve pain

Using hydrocortisone cream to relieve pain Witch hazel wipes may be effective in relieving the pain associated with anal fissures. Enemas should be avoided when an anal fissure is present. Cold packs should be applied to acute inflammation to diminish discomfort. Bulk-forming agents should be used to decrease pain associated with defecation.

A client admitted with severe diarrhea is experiencing skin breakdown from frequent stools. What is an important comfort measure for this client? A. Applying hydrocortisone cream B. Cleaning the area with soap and hot water C. Using sitz baths three times daily D. Wearing absorbent cotton underwear

Using sitz baths three times daily Clients with skin breakdown may use sitz baths for comfort 2 or 3 times daily. Barrier creams, not hydrocortisone creams, may be used. The skin should be cleaned gently with soap and warm water. Absorbent cotton underwear helps keep the skin dry, but is not a comfort measure.

A client who had surgery for inflammatory bowel disease is being discharged. The case manager will arrange for home health care follow-up. The client tells the nurse that family members will also be helping with care. What information is critically important for the nurse to provide to these collaborating members? A. A list of medical supply facilities where wound care supplies may be purchased B. Proper handwashing techniques to avoid cross-contamination of the client's wound C. The amount of pain medication that the client is allowed to take in each dose D. Written and oral instructions regarding symptoms to report to the health care provider

Written and oral instructions regarding symptoms to report to the health care provider It is most important to provide the client and case manager with both written and oral instructions on reportable symptoms to avoid the development of complications. Although instruction on proper handwashing and the client's medication regimen are important, they are not the highest priority. It will be the home health nurse's responsibility to bring supplies to the client's home.

A client with ulcerative colitis (UC) has stage 1 of a restorative proctocolectomy with ileo-anal anastomosis (RPC-IPAA) procedure performed. The client asks the nurse, "How long do people with this procedure usually have a temporary ileostomy?" How does the nurse respond? A. "It is usually ready to be closed in about 1 to 2 months." B. "This is something that you will have to discuss with your health care provider." C. "The period of time is indefinite—I am sorry that I cannot say." D. "You will probably have it for 6 months or longer, until things heal.

v"It is usually ready to be closed in about 1 to 2 months." The RPC-IPAA has become the most effective alternate method for UC clients who have surgery to remove diseased portions of intestines. Stage 1 creates a temporary ileostomy to be used while an internally created pouch is healing. Stage 2 closes the ileostomy, and the client begins to use the pouch for storage of stool. The time between the surgeries is generally 1 to 2 months. Telling the client that he or she will have to discuss it with the health care provider evades the question; the nurse can give generalities to the client based on past practice and available data. The time that the client has the ileostomy is not "indefinite." The intent of this procedure is to eliminate the need to have a permanent ileostomy. The pouch should heal in 1 to 2 months, not 6 months; this estimate is not based on the expected outcome.