NCLEX Q's
A client presents to the emergency department with upper gastrointestinal bleeding and is in moderate distress. In planning care, what is the priority nursing action for this client? 1.Assessment of vital signs 2.Completion of abdominal examination 3.Insertion of the prescribed nasogastric tube 4.Thorough investigation of precipitating events
1.Assessment of vital signs Rationale:The priority nursing action is to assess the vital signs. This would provide information about the amount of blood loss that has occurred and provide a baseline by which to monitor the progress of treatment. The client may be unable to provide subjective data until the immediate physical needs are met. Although an abdominal examination and an assessment of the precipitating events may be necessary, these actions are not the priority. Insertion of a nasogastric tube is not the priority and will require a health care provider's prescription; in addition, the vital signs should be checked before performing this procedure.
The nurse is providing care for a client with a recent transverse colostomy. Which observation requires immediate notification of the health care provider? 1.Stoma is beefy red and shiny 2.Purple discoloration of the stoma 3.Skin excoriation around the stoma 4.Semi-formed stool noted in the ostomy pouch
2.Purple discoloration of the stoma Rationale:Ischemia of the stoma would be associated with a dusky or bluish or purple color. A beefy red and shiny stoma is normal and expected. Skin excoriation needs to be addressed and treated but does not require as immediate attention as purple discoloration of the stoma. Semi-formed stool is a normal finding.
The nurse checks the gastric residual of an unconscious client receiving nasogastric tube feedings continuously at 50 mL/hr. The nurse notes that the residual is 250 mL at 0800 and 300 mL at 0900. The nurse determines that the client is experiencing which complication? 1.Air in the stomach 2.Too slow an infusion rate 3.Delayed gastric emptying 4.Early signs of peptic ulcer
3.Delayed gastric emptying Rationale:If the gastric residual is greater than 200 mL for 2 consecutive hours, the client may be experiencing delayed gastric emptying. If this occurs, the feeding is stopped, and the health care provider should be notified. The nurse should assess whether abdominal girth is enlarged and should auscultate bowel sounds to rule out intestinal obstruction. Some clients benefit from administration of metoclopramide to stimulate gastric emptying. Air in the stomach would be accompanied by abdominal distention and increased abdominal girth. The infusion rate cannot be too slow if the client is not tolerating the rate. Early peptic ulcer could be detected by a Hematest-positive gastric aspirate. In addition, agency procedures should be followed regarding gastric residuals.
The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is most appropriate? 1.Clamp the T-tube. 2.Irrigate the T-tube. 3.Document the findings. 4.Notify the health care provider.
3.Document the findings. Rationale:Following cholecystectomy, drainage from the T-tube is initially bloody and then turns a greenish-brown color. The drainage is measured as output. The amount of expected drainage will range from 500 to 1000 mL/day. The nurse would document the output.
The nurse is providing instructions to a client regarding measures to minimize the risk of dumping syndrome. The nurse should make which suggestion to the client? 1.Maintain a high-carbohydrate diet. 2.Increase fluid intake, particularly at mealtime. 3.Maintain a low Fowler's position while eating. 4.Ambulate for at least 30 minutes following each meal.
3.Maintain a low Fowler's position while eating. Rationale:The client at risk for dumping syndrome should be instructed to maintain a low Fowler's position while eating and lie down for at least 30 minutes after eating. The client also should be told that small, frequent meals are best and to avoid liquids with meals. Avoiding high-carbohydrate food sources also will assist in minimizing dumping syndrome.
The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To determine whether the problem is currently active, the nurse should assess the client for which sign(s)/symptom(s) of duodenal ulcer? 1.Weight loss 2.Nausea and vomiting 3.Pain relieved by food intake 4.Pain radiating down the right arm
3.Pain relieved by food intake Rationale:A frequent symptom of duodenal ulcer is pain that is relieved by food intake. These clients generally describe the pain as a burning, heavy, sharp, or "hungry" pain that often localizes in the mid-epigastric area. The client with duodenal ulcer usually does not experience weight loss or nausea and vomiting. These symptoms are more typical in the client with a gastric ulcer.
A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? Select all that apply. 1.Diarrhea 2.Black, tarry stools 3.Hyperactive bowel sounds 4.Gray-blue color at the flank 5.Abdominal guarding and tenderness 6.Left upper quadrant pain with radiation to the back
4,5,6 4.Gray-blue color at the flank 5.Abdominal guarding and tenderness 6.Left upper quadrant pain with radiation to the back Rationale:Grayish-blue discoloration at the flank is known as Grey-Turner's sign and occurs as a result of pancreatic enzyme leakage to cutaneous tissue from the peritoneal cavity. The client may demonstrate abdominal guarding and may complain of tenderness with palpation. The pain associated with acute pancreatitis is often sudden in onset and is located in the epigastric region or left upper quadrant with radiation to the back. The other options are incorrect.
The nurse is caring for a client with ulcerative colitis. Which finding does the nurse determine is consistent with this diagnosis? 1.Hypercalcemia 2.Hypernatremia 3.Frothy, fatty stools 4.Decreased hemoglobin
4.Decreased hemoglobin Rationale:Ulcerative colitis is an inflammatory disease of the large colon. Findings associated with ulcerative colitis include diarrhea with up to 10 to 20 liquid bloody stools per day, weight loss, anorexia, fatigue, increased white blood cell count, increased erythrocyte sedimentation rate, dehydration, hyponatremia, and hypokalemia (not hypercalcemia). Because of the loss of blood, clients with ulcerative colitis commonly have decreased hemoglobin and hematocrit levels. Clients with ulcerative colitis have bloody diarrhea, not steatorrhea (fatty, frothy, foul-smelling stools).
The nurse is planning to teach a client with gastroesophageal reflux disease (GERD) about substances to avoid. Which items should the nurse include on this list? Select all that apply. 1.Coffee 2.Chocolate 3.Peppermint 4.Nonfat milk 5.Fried chicken 6.Scrambled eggs
1,2,3,5 1.Coffee 2.Chocolate 3.Peppermint 5.Fried chicken Rationale:Foods that decrease lower esophageal sphincter (LES) pressure and irritate the esophagus will increase reflux and exacerbate the symptoms of GERD and therefore should be avoided. Aggravating substances include coffee, chocolate, peppermint, fried or fatty foods, carbonated beverages, and alcohol. Options 4 and 6 do not promote this effect.
The nurse is giving dietary instructions to a client who has a new colostomy. The nurse should encourage the client to eat foods representing which diet for the first 4 to 6 weeks postoperatively? 1.Low fiber 2.Low calorie 3.High protein 4.High carbohydrate
1.Low fiber Rationale:For the first 4 to 6 weeks after colostomy formation, the client should consume a low-fiber diet. After this period, the client should eat a high-carbohydrate, high-protein diet. The client also is instructed to add new foods, including those with fiber, one at a time to determine tolerance to that food.
The nurse has provided dietary instructions to a client with a diagnosis of peptic ulcer disease. Which client statement indicates that education was effective? 1."Baked foods such as chicken or fish are all right to eat." 2."Citrus fruits and raw vegetables need to be included in my daily diet." 3."I can drink beer as long as I consume only a moderate amount each day." 4."I can drink coffee or tea as long as I limit the amount to 2 cups daily."
1."Baked foods such as chicken or fish are all right to eat." Rationale:Dietary modifications for the client with peptic ulcer disease include eliminating foods that can cause irritation to the gastrointestinal (GI) tract. Items that should be eliminated or avoided include highly spiced foods, alcohol, caffeine, chocolate, and citrus fruits. Other foods may be taken according to the client's level of tolerance for that food.
Sulfasalazine is prescribed for a client with a diagnosis of ulcerative colitis, and the nurse instructs the client about the medication. Which statement made by the client indicates a need for further teaching? 1."The medication will cause constipation." 2."I need to take the medication with meals." 3."I may have increased sensitivity to sunlight." 4."This medication should be taken as prescribed."
1."The medication will cause constipation." Rationale:Sulfasalazine is an antiinflammatory sulfonamide. Constipation is not associated with this medication. It can cause photosensitivity, and the client should be instructed to avoid sun and ultraviolet light. It should be administered with meals, if possible, to prolong intestinal passage. The client needs to take the medication as prescribed and continue the full course of treatment even if symptoms are relieved.
A client arrives at the hospital emergency department complaining of acute right lower quadrant abdominal pain, and appendicitis is suspected. Laboratory tests are performed, and the nurse notes that the client's white blood cell (WBC) count is elevated. On the basis of these findings, the nurse should question which health care provider (HCP) prescription documented in the client's medical record? 1.Apply a cold pack to the abdomen. 2.Administer 30 mL of milk of magnesia (MOM). 3.Maintain nothing by mouth (nil per os [NPO]) status. 4.Initiate an intravenous (IV) line for the administration of IV fluids.
2.Administer 30 mL of milk of magnesia (MOM). Rationale:Appendicitis should be suspected in a client with an elevated WBC count complaining of acute right lower abdominal quadrant pain. Laxatives are never prescribed because if appendicitis is present, the effect of the laxative may cause a rupture with resultant peritonitis. Cold packs may be prescribed for comfort. The client would be NPO and given IV fluids in preparation for possible surgery.
The nurse is providing dietary instructions to a client with a diagnosis of irritable bowel syndrome. The nurse determines that education was effective if the client states the need to avoid which food? 1.Rice 2.Corn 3.Broiled chicken 4.Cream of wheat
2.Corn Rationale:The client with irritable bowel should take in a diet that consists of 30 to 40 g of fiber daily because dietary fiber will help produce bulky, soft stools and establish regular bowel habits. The client should also drink 8 to 10 glasses of fluid daily and chew food slowly to promote normal bowel function. Foods that are irritating to the intestines need to be avoided. Corn is high in fiber but can be very irritating to the intestines and should be avoided. The food items in the other options are acceptable to eat.
The nurse is caring for a client admitted to the hospital with a suspected diagnosis of acute appendicitis. Which laboratory result should the nurse expect to note if the client does have appendicitis? 1.Leukopenia with a shift to the left 2.Leukocytosis with a shift to the left 3.Leukopenia with a shift to the right 4.Leukocytosis with a shift to the right
2.Leukocytosis with a shift to the left Rationale:Laboratory findings do not establish the diagnosis of appendicitis, but there is often an elevation of the white blood cell count (leukocytosis) with a shift to the left (an increased number of immature white blood cells). Options 1, 3, and 4 are incorrect because they are not associated findings in acute appenditis.
The nurse is caring for a client who is prescribed a nasogastric (NG) tube for the purpose of stomach decompression. The nurse should anticipate a health care provider prescription for which type of suction? 1.High and intermittent 2.Low and intermittent 3.High and continuous 4.Low and continuous
2.Low and intermittent Rationale:Gastric mucosa can be traumatized and pulled into the tube if the suction pressure is placed on high or if the suction is continuous. The suction should be set on low pressure and intermittent suction control.
The nurse has taught the client about an upcoming endoscopic retrograde cholangiopancreatography (ERCP) procedure. The nurse determines that the client needs further information if the client makes which statement? 1."I know I must sign the consent form." 2."I hope the throat spray keeps me from gagging." 3."I'm glad I don't have to lie still for this procedure." 4."I'm glad some intravenous medication will be given to relax me."
3."I'm glad I don't have to lie still for this procedure." Rationale:The client does have to lie still for ERCP, which takes about 1 hour to perform. The client also has to sign a consent form. Intravenous sedation is given to relax the client, and an anesthetic spray is used to help keep the client from gagging as the endoscope is passed.
A client who has undergone gastric surgery has a nasogastric (NG) tube connected to low intermittent suction that is not draining properly. Which action should the nurse take initially? 1.Call the surgeon to report the problem. 2.Reposition the NG tube to the proper location. 3.Check the suction device to make sure it is working. 4.Irrigate the NG tube with saline to remove the obstruction.
3.Check the suction device to make sure it is working. Rationale:After gastric surgery, the client will have an NG tube in place until bowel function returns. It is important for the NG tube to drain properly to prevent abdominal distention and vomiting. The nurse must ensure that the NG tube is attached to suction at the level prescribed and that the suction device is working correctly. The tip of the NG tube may be placed near the suture line. Because of this possibility, the nurse should never reposition the NG tube or irrigate it. If the NG tube needs to be repositioned, the nurse should call the surgeon, who would do this repositioning under fluoroscopy.
The nurse is performing an assessment on a client with suspected acute pancreatitis. Which complaint made by the client supports the diagnosis? 1."I have epigastric pain radiating to my neck." 2."I have severe abdominal pain that is relieved after vomiting." 3."My temperature has been running between 96°F (35.5°C) and 97°F (36.1°C)." 4."I've been experiencing constant, severe abdominal pain that is unrelieved by vomiting."
4."I've been experiencing constant, severe abdominal pain that is unrelieved by vomiting." Rationale:Nausea and vomiting are common presenting manifestations of acute pancreatitis. A hallmark symptom is severe abdominal pain that is not relieved by vomiting. The vomitus characteristically consists of gastric and duodenal contents. Fever also is a common sign. Epigastric pain radiating to the neck area is not a characteristic symptom.
The nurse is performing an assessment on a client with acute pancreatitis who was admitted to the hospital. Which assessment question would most specifically elicit information regarding the pain that is associated with acute pancreatitis? 1."Does the pain in your stomach radiate to your back?" 2."Does the pain in your lower abdomen radiate to your hip?" 3."Does the pain in your lower abdomen radiate to your groin?" 4."Does the pain in your stomach radiate to your lower middle abdomen?"
1."Does the pain in your stomach radiate to your back?" Rationale:The pain that is associated with acute pancreatitis is often severe, is located in the epigastric region, and radiates to the back. The remaining options are incorrect because they are not specific for the pain experienced by the client with pancreatitis.
The nurse inspects the color of the drainage from a nasogastric tube on a postoperative client approximately 24 hours after gastric surgery. Which finding indicates the need to notify the health care provider (HCP)? 1.Dark red drainage 2.Dark brown drainage 3.Green-tinged drainage 4.Light yellowish-brown drainage
1.Dark red drainage Rationale:For the first 12 hours after gastric surgery, the nasogastric tube drainage may be dark brown to dark red. Later, the drainage should change to a light yellowish-brown color. The presence of bile may cause a green tinge. The HCP should be notified if dark red drainage, a sign of hemorrhage, is noted 24 hours postoperatively.
After performing an initial abdominal assessment on a client with nausea and vomiting, the nurse should expect to note which finding? 1.Waves of loud gurgles auscultated in all 4 quadrants 2.Low-pitched swishing auscultated in 1 or 2 quadrants 3.Relatively high-pitched clicks or gurgles auscultated in all 4 quadrants 4.Very high-pitched, loud rushes auscultated especially in 1 or 2 quadrants
1.Waves of loud gurgles auscultated in all 4 quadrants Rationale:Although frequency and intensity of bowel sounds vary depending on the phase of digestion, normal bowel sounds are relatively high-pitched clicks or gurgles. Loud gurgles (borborygmi) indicate hyperperistalsis and are commonly associated with nausea and vomiting. A swishing or buzzing sound represents turbulent blood flow associated with a bruit. Bruits are not normal sounds. Bowel sounds are very high-pitched and loud (hyperresonance) when the intestines are under tension, such as in intestinal obstruction. Therefore, options 2, 3, and 4 are incorrect.
The nurse is providing instructions to a client with a colostomy about measures to reduce the odor from the colostomy. Which client statement indicates that the educational session was effective? 1."I should be sure to eat at least 1 cucumber every day." 2."Beet greens, parsley, or yogurt will help to control the colostomy odor." 3."I will need to increase my egg intake and try to eat ½ to 1 egg per day." 4."Green vegetables such as spinach and broccoli will prevent odor, and I should eat these foods every day."
2."Beet greens, parsley, or yogurt will help to control the colostomy odor." Rationale:The client should be taught to include deodorizing foods in the diet, such as beet greens, parsley, buttermilk, and yogurt. Spinach also may reduce odor, but it is a gas-forming food and should be avoided. Cucumbers, eggs, and broccoli also are gas-forming foods and should be avoided or limited by the client.
The nurse is caring for a client following a gastrojejunostomy (Billroth II procedure). Which postoperative prescription should the nurse question and verify? 1.Leg exercises 2.Early ambulation 3.Irrigating the nasogastric tube 4.Coughing and deep-breathing exercises
3.Irrigating the nasogastric tube Rationale:In a gastrojejunostomy (Billroth II procedure), the proximal remnant of the stomach is anastomosed to the proximal jejunum. Patency of the nasogastric tube is critical for preventing the retention of gastric secretions. The nurse should never irrigate or reposition the gastric tube after gastric surgery, unless specifically prescribed by the health care provider. In this situation, the nurse should clarify the prescription. Options 1, 2, and 4 are appropriate postoperative interventions.
The nurse is providing discharge instructions to a client following gastrectomy and should instruct the client to take which measure to assist in preventing dumping syndrome? 1.Ambulate following a meal. 2.Eat high-carbohydrate foods. 3.Limit the fluids taken with meals. 4.Sit in a high Fowler's position during meals.
3.Limit the fluids taken with meals. Rationale:Dumping syndrome is a term that refers to a constellation of vasomotor symptoms that occurs after eating, especially following a gastrojejunostomy (Billroth II procedure). Early manifestations usually occur within 30 minutes of eating and include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down. The nurse should instruct the client to decrease the amount of fluid taken at meals and to avoid high-carbohydrate foods, including fluids such as fruit nectars; to assume a low Fowler's position during meals; to lie down for 30 minutes after eating to delay gastric emptying; and to take antispasmodics as prescribed.
The nurse is caring for a client after abdominal surgery and creation of a colostomy. The nurse is assessing the client for a prolapsed stoma and should expect to note which observation if this is present? 1.A sunken and hidden stoma 2.A narrow and flattened stoma 3.A stoma that is dusky or bluish 4.A stoma that is elongated with a swollen appearance
4.A stoma that is elongated with a swollen appearance Rationale:A prolapsed stoma is one in which the bowel protrudes, causing an elongated and swollen appearance of the stoma. A retracted stoma is characterized by sinking of the stoma. A stoma with a narrow opening is described as being stenosed. Ischemia of the stoma would be associated with a dusky or bluish color.
A client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery? 1.Folate deficiency 2.Malabsorption of fat 3.Intestinal obstruction 4.Fluid and electrolyte imbalance
4.Fluid and electrolyte imbalance Rationale:A frequent complication that occurs following ileostomy is fluid and electrolyte imbalance. The client requires constant monitoring of intake and output to prevent this from occurring. Losses require replacement by intravenous infusion until the client can tolerate a diet orally. Intestinal obstruction is a less frequent complication. Fat malabsorption and folate deficiency are complications that could occur later in the postoperative period.
A client had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse? 1.This is a normal, expected event. 2.The client is experiencing early signs of ischemic bowel. 3.The client should not have the nasogastric tube removed. 4.This indicates inadequate preoperative bowel preparation.
1.This is a normal, expected event. Rationale:As peristalsis returns following creation of a colostomy, the client begins to pass malodorous flatus. This indicates returning bowel function and is an expected event. Within 72 hours of surgery, the client should begin passing stool via the colostomy. Options 2, 3, and 4 are incorrect interpretations.
The nurse provides instructions to a client about measures to treat inflammatory bowel syndrome (IBS). Which statement by the client indicates a need for further teaching? 1."I need to limit my intake of dietary fiber." 2."I need to drink plenty, at least 8 to 10 cups daily." 3."I need to eat regular meals and chew my food well." 4."I will take the prescribed medications because they will regulate my bowel patterns."
1."I need to limit my intake of dietary fiber." Rationale:IBS is a functional gastrointestinal disorder that causes chronic or recurrent diarrhea, constipation, and/or abdominal pain and bloating. Dietary fiber and bulk help to produce bulky, soft stools and establish regular bowel elimination habits. Therefore, the client should consume a high-fiber diet. Eating regular meals, drinking 8 to 10 cups of liquid a day, and chewing food slowly help to promote normal bowel function. Medication therapy depends on the main symptoms of IBS. Bulk-forming laxatives or antidiarrheal agents or other agents may be prescribed.
The nurse is providing discharge teaching for a client with newly diagnosed Crohn's disease about dietary measures to implement during exacerbation episodes. Which statement made by the client indicates a need for further instruction? 1."I should increase the fiber in my diet." 2."I will need to avoid caffeinated beverages." 3."I'm going to learn some stress reduction techniques." 4."I can have exacerbations and remissions with Crohn's disease."
1."I should increase the fiber in my diet." Rationale:Crohn's disease is an inflammatory disease that can occur anywhere in the gastrointestinal tract but most often affects the terminal ileum and leads to thickening and scarring, a narrowed lumen, fistulas, ulcerations, and abscesses. It is characterized by exacerbations and remissions. If stress increases the symptoms of the disease, the client is taught stress management techniques and may require additional counseling. The client is taught to avoid gastrointestinal stimulants containing caffeine and to follow a high-calorie and high-protein diet. A low-fiber diet may be prescribed, especially during periods of exacerbation.
The nurse has provided home care instructions to a client who had a subtotal gastrectomy. The nurse instructs the client on the signs and symptoms associated with dumping syndrome. Which client statement indicates that teaching was effective? 1."It will cause diaphoresis and diarrhea." 2."I have to monitor for hiccups and diarrhea." 3."It will be associated with constipation and fever." 4."I have to monitor for fatigue and abdominal pain."
1."It will cause diaphoresis and diarrhea." Rationale:Dumping syndrome occurs after gastric surgery because food is not held for as long in the stomach and is dumped into the intestine as a hypertonic mass. This causes fluid to shift into the intestine, causing cardiovascular and gastrointestinal symptoms. Symptoms can typically include weakness, dizziness, diaphoresis, flushing, hypotension, abdominal pain and distention, hyperactive bowel sounds, and diarrhea. The remaining options are not signs of dumping syndrome.
The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the most appropriate nursing intervention? 1.)Notify the health care provider (HCP). 2.)Administer the prescribed pain medication. 3.)Call and ask the operating room team to perform surgery as soon as possible. 4.)Reposition the client and apply a heating pad on the warm setting to the client's abdomen.
1.)Notify the health care provider (HCP). Rationale:On the basis of the signs and symptoms presented in the question, the nurse should suspect peritonitis and notify the HCP. Administering pain medication is not an appropriate intervention. Heat should never be applied to the abdomen of a client with suspected appendicitis because of the risk of rupture. Scheduling surgical time is not within the scope of nursing practice, although the HCP probably would perform the surgery earlier than the prescheduled time.
Diphenoxylate hydrochloride with atropine sulfate is prescribed for a client with ulcerative colitis. The nurse should monitor the client for which therapeutic effect of this medication? 1.Decreased diarrhea 2.Decreased cramping 3.Improved intestinal tone 4.Elimination of peristalsis
1.Decreased diarrhea Rationale:Diphenoxylate hydrochloride with atropine sulfate is an antidiarrheal product that decreases the frequency of defecation, usually by reducing the volume of liquid in the stools. The remaining options are not associated therapeutic effects of this medication.
The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which findings indicate this occurrence? 1.Sweating and pallor 2.Bradycardia and indigestion 3.Double vision and chest pain 4.Abdominal cramping and pain
1.Sweating and pallor Rationale:Early manifestations of dumping syndrome occur 5 to 30 minutes after eating. Symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down.
The nurse is preparing to teach a client with a new colostomy about how to perform a colostomy irrigation. Which information should the nurse include in the teaching plan? 1.Use 500 to 1000 mL of warm tap water. 2.Suspend the irrigant 36 inches above the stoma. 3.Insert the irrigation cone ½ inch into the stoma. 4.If cramping occurs, open the irrigation clamp farther.
1.Use 500 to 1000 mL of warm tap water. Rationale:The usual procedure for colostomy irrigation includes using 500 to 1000 mL of warm tap water. The solution is suspended 18 inches above the stoma. The cone is inserted 2 to 4 inches into the stoma but should never be forced. If cramping occurs, the client should decrease the flow rate of the irrigant as needed by closing the irrigation clamp.
The nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment finding would most likely indicate perforation of the ulcer? 1.Bradycardia 2.Numbness in the legs 3.Nausea and vomiting 4.A rigid, boardlike abdomen
4.A rigid, boardlike abdomen Rationale:Perforation of an ulcer is a surgical emergency and is characterized by sudden, sharp, intolerable severe pain beginning in the mid-epigastric area and spreading over the abdomen, which becomes rigid and boardlike. Nausea and vomiting may occur. Tachycardia may occur as hypovolemic shock develops. Numbness in the legs is not an associated finding.
A client with acute ulcerative colitis requests a snack. Which is the most appropriate snack for this client? 1.Carrots and ranch dip 2.Whole-grain cereal and milk 3.A cup of popcorn and a cola drink 4.Applesauce and a graham cracker
4.Applesauce and a graham cracker Rationale:The diet for the client with ulcerative colitis should be low fiber (low residue). The nurse should avoid providing foods such as whole-wheat grains, nuts, and fresh fruits or vegetables. Typically, lactose-containing foods also are poorly tolerated. The client also should avoid caffeine, pepper, and alcohol.
