practice questions

The nurse is monitoring a client diagnosed with appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begns to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the appropriate nursing intervention? 1. Notify the Physician 2. Administer the prescribed pain medication 3. Call and ask the operating room team to perform the surgery as soon as possible 4. Reposition the client and apply a heating pad on warm setting to the client's abdomen

1 (1. Based on the assessment information the nurse should suspect peritonitis, a complication that is associated with appendicitis, and notify the physician. 2. Administering pain medication is not an appropriate intervention 3. Scheduling surgical time is not within the scope of practice of an RN. 4. Heat should never be applied to the abdomen of a patient suspected of having peritonitis because of the risk of rupture.)

the client has dark, watery, and shiny appearing stool. which intervention should the nurse implement first? 1. check for fecal impaction 2. encourage the client to drink fluids 3. check the chart for sodium and potassium levels 4. apply a protective barrier cream to the perianal area

1 (this is a symptom of diarrhea moving around an impaction higher up in the colon. the nurse should assess for an impaction when observing this finding.)

which s/s should the nurse expect to find in a client dx with ulcerative colitis? 1. twenty bloody stools a day 2. oral temp of 102 3. hard rigid abd 4. urinary stress incontinence

1 (twenty bloody stools a day: the colon is ulcerated and unalbe to absorb water, resulting in bloody diarrhea. ten to 20 bloody diarrhea stools is the most common symptom of ulcerative colitis)

when irrigating a descending colostomy with 1000 mL of warm tap water, the nurse would expect? 1. complete return of the solution plus soft or formed feces 2. complete return of the solution mixed with liquid stool 3. evacuation of soft and formed feces only 4. evacuation of tap water only

1 ( complete return of the solution should occur with the evacuation of soft or formed feces.)

a 27 y/o client returns to the hospital room after a barium enema. an important part of his nursing care at this point in time is to: 1. obtain an order for a cleansing enema 2. observe for signs of renal damage 3. maintain bed rest until a physician orders otherwise 4. observe for an allergic reaction to the barium

1 (a cleansing enema is needed to clean all of the barium out of the GI tract, it can obstruct the appendix)

the client dx with IBD is prescribed tpn, which intervention should the nurse implement 1. check the clients glucose level 2. administer an oral hypoglycemic 3. assess the peripheral iv site 4. monitor the clients oral food intake

1 (check the clients glucose level: TPN is high in dextrose, which is glucose, therefore, the clients blood glucose level must be monitored closely 2. the client may be on sliding scale regular insulin coverage for the high glucose level 3. the tpn must be administered via a subclavian line bc of the high glucose level 4. the client is npo to put the bowel at rest, which is the rationale for tpn)

while receiving a soapsuds enema, the client complains of abdominal cramps. the nurse should: 1. temporarily stop the flow of the enema 2. tell the client to breathe slowly through the mouth 3. raise the height of the enema container 4. clamp the tubing and withdraw the rectal tube

1 (cramping is temporarily relieved by lowering the container and/or clamping the tubing to temporarily stop the flow of enema solution. once cramping passes, the enema is continued until the entire amount of fluid is administered. There is no need to withdraw the tube, cramping is very common during procedure. Mouth breathing may help relax the pt but will not help the cramping.)

the client with acute diverticulitis has a ng tube draining green liquid bile. which intervention should the nurse implement? 1. document the findings as normal 2. assess the clients bowel sounds 3. determine the clients last bowel movement 4. insert the NG tube at least 2 more inches

1 (document the findings as normal; green bile contains hydrochloric acid and should be draining from the NG tube; therefore, the nurse should take no action and document the findings.)

the client has an eviscerated abdominal wound. which intervention should the nurse implement? 1. apply sterile normal saline dressing 2. use sterile gloves to replace protruding parts 3. place the client in reverse trendelenburg position 4. administer iv antibiotic stat

1 (evisceration is a life threatening condition in which the abdominal contents protrude through the ruptured incision. the nurse must protect the bowel from the environment by placing a sterile normal saline gauze on it, which prevents the intestines from drying out and necrossing.)

a 56 y/o woman was placed on strict I and O. her dx is renal insufficiency. the i and O for the last 24 hrs was 3000mL in and 1000mL out. based on this information, the nurse anticipates her wt to: 1. increase by 2 kg 2. increase by approximately 2 lb 3. decrease by approximately 2 lb 4. remain the same

1 (intake greater than output would reflect an increase in wt. 1L of fluid is equal to 1 kg (2.2lb) in wt. intake exceeds output by 2000mL (2kg) The nurse would anticipate the wt to increase by 2 kg or 4.4 lbs)

the client is dx with crohns disease, also known as regional enteritis. which statement by the client supports this dx? 1. my pain goes away when i have a bowel movement 2. i have bright red blood in my stool all the time 3. i have episodes of diarrhea and constipation 4. my abdomen is hard and rigid and i have a fever

1 (my pain goes away when i have a bowel movement: the terminal ileum is the most common site for regional enteritis, which causes rt lower quadrant pain that is relieved by defecation. episodes of diarrhea and constipation may be a s/s of colon cancer not crohns.)

the nurse caring for a client 1 day postop sigmoid resection notes a moderate amount of dark reddish brown drainage on the midline abdominal incision. which intervention should the nurse implement first? 1. mark the drainage on the dressing with the time and date 2. change the dressing immediately using sterile technique 3. notify the hcp immediately 4. reinforce the dressing with a sterile gauze pad

1 (the nurse should mark the drainage on the dressing to determine if active bleeding is occuring, because dark reddish brown drainage indicates old blood. this allows the nurse to assess what is actually happening)

a client admitted for a dx workup passes a stool that is of normal size in some areas but stringlike in others. the nurse would: 1. document the finding on the chart 2. ignore the appearance of the stool 3. obtain an order for a laxative 4. check for fecal impaction

1 (the stool is indicative of regional enteritis, or crohns disease; documentation of the stool would aid dx. the stool shouldnt be ignored. a laxative isnt indicated. the stool is more indicative of a regional enteritirs (crohns) than a fecal impaction)

the client dx with acute diverticulitis is c/o severe abdominal pain. on assessment, the nurse finds a hard, rigid abdomen and T 102. which intervention should the nurse implement? 1. notify the hcp 2. prepare to administer a fleets enema 3. administer an antipyretic suppository 4. continue to monitor the client closely

1 (these are signs of peritonitis, which is life threatening. the hcp should be notified immediately.)

the nurse is teaching a class on diverticulosis. which interventions should the nurse discuss when teaching ways to prevent an acute exacerbation of diverticulosis? select all that apply 1. eat a high fiber diet 2. increase fluid intake 3. elevate the HOB after eating 4. walk 30 mins a day 5. take an antacid every 2 hours

1,2,4 (a high fiber diet will help to prevent constipation, which is the primary reason for diverticulitis. increased fluids will help keep the stool soft and prevent constipation. elevating the HOB will NOT do anything for preventing diverticulitis. Exercise will help prevent constipation. no meds are prescribed to prevent an acute exacerbation of diverticulitis.)

the nurse is planning the care of a client who has had an abdominal perineal resection for cancer of the colon, which interventions should the nurse implement? select all that apply 1. provide meticulous skin care to stoma 2. assess the flank incision 3. maintain the indwelling cath 4. irrigate the JP drains every shift 5. position the client semirecumbent

1,3,5 (colostomy stomas are opening through the abdominal wall into the colon, through which feces exit the body. feces can be irritating to the abd skin, so careful and thourough skin care is needed. There are midline and perineal incisions not flank incisions. because of the perineal wound, the client will have an indwelling catheter to keep urine out of the incision. JP drains are emptied every shift, but not irrigated. The client should not sit upright because this causes pressure on the perinuem)

a 16 y/o client c/o abdominal pain. the nurse: 1. recommends a laxative 2. checks for rebound tenderness 3. applies a heating pad 4. calls the physician

2

the nurse obtains a report from the lab stating her clients serum potassium is 4.3 mEq/L Which action should she perform next? 1. notify the dr immediately, because the value is dangerously low 2. note the value in her notes, and notify the dr when he makes rounds 3. this is a panic value. the level is dangerously high, and the dr must be notified immediately 4. offer the client potassium rich foods such as orange juice and bananas.

2 (A normal potassium level is 3.5-5, therefore this is WNL)

the nurse is caring for clients on a surgical unit. which client should the nurse assess first? 1. the client who had an inguinal hernia repair and has not voided in 4 hours 2. the client who was admitted with abdominal pain who suddenly has no pain 3. the client 4 hours postop abdominal surgery with no bowel sounds 4. the client who is 1 day postappendectomy and is being discharged

2 (a sudden cessation of pain may indicate a ruptured appendix, which could lead to peritonitis, a life threatening complication; therefore, the nurse should assess this client first)

the client is 1 day postop major abdominal surgery. which client problem is priority? 1. impaired skin integrity 2. fluid and electrolyte imbalance 3. altered bowel elimination 4. altered body image

2 (after abdominal surgery, the body distributes fluids to the affected area as part of the healing process. these fluids are shifted from the intravascular compartment to the interstitial space, which causes potential fluid and electrolyte imbalance)

the client dx with IBD has a serum potassium level of 3.4 mEq/L. which action should the nurse implement first? 1. notify the hcp 2. assess the client for muscle weakness 3. request telemetry for the client 4. prepare to administer potassium IV

2 (assess the client for muscle weakness: muscle weakness may be a sign of hypokalemia; hypokalemia can lead to cardiac dysrhythmias and can be life threatening. assessment is priority for a potassium level just below normal level which is 3.5-5.5 1. the hcp should be notified so potassium supplements can be ordered, but this is not the first action 3. hypokalemia can lead to cardiac dysrhthmias, therefore, requesting telemetry is appropriate, but its not the first intervention 4. the client will need potassium to correct the hypokalemia, but its not the first intervention)

the dietitian and the nurse in a long term care facility are planning the menu for the day. which foods should be recommended for the immobile clients for whom swallowing is not an issue? 1. cheeseburger and milk shake 2. canned peaches and a sandwich on whole wheat bread 3. mashed potatoes and mechanically ground red meat 4. biscuits and gravy with bacon

2 (canned peaches are soft and can be chewed and swallowed easily while providing some fiber; whole wheat bread is higher in fiber than white bread. these foods will be helpful for clients whose gastric motility is slowed as a result of lack of exercise or immobility.)

a 34 y/o client is hospitalized for crohns disease; the nurse should assess this client frequently for: 1. v/s, bleeding and diarrhea 2. skin tugor, urinary ouput, and electrolyte report 3. breath sounds, pupil size, and change in mental status 4. peripheral perfusion, skin color, and muscle twitching

2 (fluid volume deficit and electrolyte imbalances could occur, they need to be detected early. vital signs may be taken routinely, bleeding should not be a problem, and diarrhea would be monitored as it occurs. perfusion could be reflection of fluid balance, and muscle twitching could indicate electrolyte imbalance, but the variables listed in rationale 2 would be more likely to detect fluid and electrolyte imbalances earlier)

the client dx with ulcerative colitis has an ileostomy. which statement indicates the client needs more teaching concerning the ileostomy? 1. my stoma should be pink and moist 2. i will irrigate my ileostomy every morning 3. if i get a red bumpy, itchy rash i will call my hcp 4. i will change my pouch if it starts leaking

2 (i will irrigate my ileostomy every morning: an ileostomy will drain liquid all the time and shouldnt routinely be irrigated. a sigmoid colostomy may need daily irrigation to evacuate feces)

the client is dx with an acute exacerbation of ulcerative colitis. which intervention should the nurse implement? 1. provide a low residue diet. 2. rest the clients bowels 3. assess vs daily 4. administer antacid orally

2 (rest the clients bowels: whenever a client has an acute exacerbation of a gastrointestinal d/o, the first intervention is to place the bowel on rest. the client should be npo with iv fluids to prevent dehydration 1. the client should be npo 3. the vs must be taken more often than daily in a client who is having an acute exacerbation of ulcerative colitis 4. the client will receive anti inflammatory and antidiarrheal meds, not antacids, which are used for gastroenteritis)

the client is admitted to the medical floor with acute diverticulosis. which collaborative intervention should the nurse anticipate the hcp ordering? 1. administer tpn 2. maintain NPO and ng tube 3. maintain on a high fiber diet and increase fluids 4. obtain consent for abdominal surgery

2 (the bowel must be put at rest. therefore, the nurse should anticipate orders for maintaining the client NPO and a ng tube)

the client with a new colostomy is being discharged. which statement made by the client indicates the need for further teaching? 1. if i notice any skin breakdown, i will call the hcp 2. i should drink only liquids until the colostomy starts to work 3. i should not take a tub bath until the hcp okays it 4. i should not drive or lift more than 5 lbs

2 (the client should be on a regular diet, and the colostomy will have been working for several days prior to discharge. the clients statement indicates the need for further teaching. until the incision is completely healed, the client should not sit in bath water because of the potential contamination of the wound by the bath water. the client has had minor surgery and should limit straining and lifting for a while.)

a client with chronic CHF is being discharged on furosemide (lasix). the dietitian advises a diet high in potassium. which food choice listed below has the most potassium content? 1. peanuts 2. peaches 3. broccoli 4. milk

2 (the following foods are rich in potassium: bananas, cantaloupe, apricots, peaches, dates, raisins, oj, tomato juice, avocados, navy beans, squash, carrots, and cauliflower)

the nurse is preparing to administer the initial dose of an aminoglycoside antibiotic to the client dx with acute diverticulitis, which intervention should the nurse implement? 1. obtain a serum trough level 2. ask about drug allergies 3. monitor the peak level 4. assess the vs

2 (the nurse should always ask about allergies to medication when administering meds, but especially when administering antibiotics, which are notorious for allergic reactions)

after abdominal surgery your client has a salem sump tube that is draining excessive amounts of fluid. which acid base disturbance is most likely to occur? 1. metabolic acidosis 2. metabolic alkalosis 3. respiratory acidosis 4. respiratory alkalosis

2 (the salem sump tube drains stomach contents that are acidic because of the hydrocholoric acid. the loss of stomach acid sets up a situation in which the body then has too much base for the amount of acid present. this situation can also occur when excessive vomiting occurs. this is a metabolic problem; thus metabolic alkalosis occurs)

the charge nurse has just received the shift report. which client should the nurse see first? 1. the client dx with crohns disease who had 2 semiformed stools on the previous shift. 2. the elderly client admitted from another facility who is c/o constipation 3. the client dx with AIDS who had a 200 mL diarrhea stool and has elastic skin tissue turgor 4. the client dx with hemorrhoids who had some spotting of bright red blood on the toilet tissue.

2 (this client has just arrived, so the nurse doesn't know if the complaint is valid and needs intervention unless assessed. the elderly have difficulty with constipation as a result of decreased gastric motility, medications, poor diet, and immobility)

the 84 y/o client comes to the clinic c/o rt lower abdominal pain. which question is most appropriate for the nurse to ask the client? 1. when was your last bowel movement 2. did you have a high fat meal last night 3. can you describe the type of pain 4. have you been experiencing any gas

3 (an elderly client may experience a ruptured appendix with minimal pain; therefore, the nurse should assess the characteristics of the pain)

the client is dx with peritonitis. which assessment data indicate to the nurse the clients condition is improving? 1. the client is using more pain medication on a daily basis. 2. the clients ng tube is draining coffee ground material 3. the client has a decrease in temp and a soft abdomen 4. the client has had 2 soft, formed bowel movements

3 (bc the signs of peritonitis are elevated temp and rigid abdomen, a reversal of these signs indicates the client is getting better.)

a 60 y/o man has an ileostomy. he is admitted to the hospital with nausea, vomiting, diarrhea, and severe dehydration. what IV fluids would this nurse expect the physician to order? 1. 0.9% normal saling (NS) with added potassium 2. 0.9 NS 3. 0.45 (1/2 NS) with added potassium ( 4. 3% NS with added potassium

3 (because of fluid loss from vomitingand diarrhea, the client needs a hypotonic solution (0.45 NS). hypotonic fluids allow fluid to reenter the cell. potassium should be added because of the loss of potassium rich fluid through vomiting and diarrhea.)

the nurse is discussing the therapeutic diet for the client dx with diverticulosis. which meal indicates the client understands the discharge teaching? 1. fried fish, mashed potatoes, and iced tea 2. ham sandwich, applesauce, and whole milk 3. chicken salad on whole wheat bread and water 4. lettuce, tomato, and cucumber salad and coffee.

3 (chicken salad, which has vegetables such as celery, grapes, and apples, and whole wheat bread are high in fiber, which is the therapeutic diet prescribed for clients with diverticulosis. an adequate intake of water helps prevent constipation. fried foods increase cholesterol. mashed potatoes do not have the peel, which is needed for increased fiber. applesauce does not have the peel, which is needed for increased fiber, and the option does not identify which type of bread; whole milk is high in fat

the nurse is working in an outpatient clinic. which client is most likely to have a dx of diverticulosis? 1. a 60 y/o male with a sedentary lifestyle 2. a 72 y/o female with multiple childbirths 3. a 63 y/o female with hemorrhoids 4. a 40 y/o male with a family hx of diverticulosis

3 (hemorrhoids would indicate the client has chronic constipation, which is a strong risk factor for diverticulosis. constipation increases the intraluminal pressure in the sigmoid colon, leading to weakness in the intestinal lining, which, in turn, causes outpouchings, or diverticula.)

the client dx with crohns disease is crying and tells the nurse, i cant take it anymore. i never know when i will get sick and end up in the hosp. which statement is the nurses best response? 1. i understand how frustrating this must be for you 2. you must keep thinking about the good things in your life 3. i can see you are very upset. ill sit down and we can talk 4. are you thinking about doing anything like committing suicide?

3 (i can see you are very upset. ill sit down and we can talk: the client is crying and is expressing feelings of powerlessness; therefore, the nurse should allow the client to talk)

the client being admitted from the emergency department is dx with a fecal impaction. which nursing intervention should be implemented? 1. administer an antidiarrheal med every day and PRN 2. perform bowel training every 2 hours 3. administer an oil retention enema 4. prepare for an upper gastrointestinal (UGI) series xray

3 (oil retention enemas will help to soften the feces and evacuate the stool. 1. antidiarrheal med would slow down the peristalsis in the colon, worsening the problem. 2. the client has an immediate need to evacuate the bowel, not a need for bowel training. 4. a UGI series adds barium to the already hardened stool in the colon. barium enemas cray the colon; a UGI series xrays the stomach and jejunum)

the client dx with an acute exacerbation of IBD. which priority intervention should the nurse implement first? 1. weigh the client daily and document in the clients chart 2. teach coping strategies such as dietary modifications 3. record the frequency, amount, and color of stools 4. monitor the clients oral fluid intake every shift

3 (record the frequency, amount, and color of stools: the severity of the diarrhea helps determine the need for fluid replacement. the liquid stool should be measured as part of the total output. 1. weighing the pt will be included but not the priority 2.coping strategies help develop healthy ways to deal with this chronic disease, which has remissions and exacerbations but its not the priority 4. the client will be NPO when theres an acute exacerbation to allow the bowel to rest)

the client dx with ulcerative colitis is prescribed a low residue diet. which meal selection indicates the client understands the diet teaching 1. grilled hamburger on a wheat bun and fried potatoes 2. a chicken salad sandwich and lettuce and tomato salad 3. roast pork, white rice, and plain custard 4. fried fish, whole grain pasta, and fruit salad

3 (roast pork, white rice, and plain custard: a low residue diet is low fiber diet. products made of refined flour or finely milled grains, along with roasted baked or broiled meats are recommended. Raw vegetables should be avoided because this is roughage)

the client with type 2 diabetes is prescribed prednisone, a steroid, for an acute exacerbation of inflammatory bowel disease. which intervention should the nurse discuss with the client? 1. take this med on an empty stomach 2. notify the hcp if experiencing a moon face 3. take the steroid medicaiton as prescribed 4. notify the hcp if the blood glucose is over 160

3 (take the steroid medication as prescribed: the medicine must be tapered off to prevent adrenal insufficiency, therefore, the client must take this medication as prescribed. 1. steroids can erode the stomach and should be taken with food 2. a moon face is an expected side effect of steroids 4. steroids may increase the clients blood glucose, but diabetic medication regimens are usually not altered for the short period of time the client with an acute exacerbation is prescribed steroids)

the nurse is caring for clients in an outpatient clinic. which information should the nurse teach regarding the american cancer societys recommendations for the early detection of colon cancer? 1. beginning at age 60, a digital rectal exam should be done yearly 2. after reaching middle age, a yearly fecal occult blood test should be done 3. have a colonoscopy at age 50 and then once every 5 to 10 yrs 4. a flexible sigmoidoscopy should be done yearly after age 40

3 (the american cancer society recommends a colonoscopy at age 50 and every 5 to 10 yrs thereafter, and a flexible sigmoidoscopy and a barium enema every 5 yrs)

client is admitted to the medical unit with a dx of acute diverticulitis. which hcp order should the nurse question? 1. insert an ng tube 2. start an IV with D5W at 125 mL/hr 3. put client on a clear liquid diet 4. place client on bedrest with bathroom privileges

3 (the nurse should question a clear liquid diet bc the bowel must be put on total rest, which means NPO. the client will have a ng tube bc the client will be NPO, which will decompress the bowel and remove hydrochloric acid. preventing dehydration is a priority with the client who is NPO. The client is in severe pain and should be on bedrest, which will help rest the bowel.)

the client presents with a complete blockage of the large intestine from a tumor. which hcp order would the nurse question? 1. obtain consent for a colonoscopy and biopsy 2. start an IV of 0.9% saline at 125 mL/hr 3. administer 3 liters of GoLYTELY 4. give tap water enemas until it is clear

3 (this client has an intestinal blockage from a solid tumor blocking the colon. although the client needs to be cleaned out for the colonoscopy, GoLYTELY could cause severe cramping without a reasonable benefit to the client and could cause a medical emergency. tap water enemas until clear would be instilling water from below the tumor to try to rid the colon of any feces. the client can expel this water)

which of the following would be included in the routine care of an ileostomy? 1. bowel training, thus eliminating need to wear appliance 2. irrigating the stoma daily to promote continence 3. providing a skin barrier around the stoma 4. administering a stool softner daily

3 (to maintain skin integrity, the nurse would ensure that the skin is clean and dry and then apply a skin barrier and a properly fitting appliance. bowel training isnt done with ileostomies bc the contets are liquid and contain digestive enzymes. Ileostomies are not routinely irrigated. because the contents are liquid stool softeners are not needed)

A client with acute appendicitis develops a fever, tachycardia, and hypotension. Based on these assessment findings, the nurse should further assess the client for which of the following complications?... "1. Deficient fluid volume. 2. Intestinal obstruction. 3. Bowel ischemia. 4. Peritonitis

4

the male client had abdominal surgery and the nurse suspects the client has peritonitis. which assessment data support the dx of peritonitis? 1. absent bowel sounds and potassium level of 3.9 mEq 2. abdominal cramping and hemoglobin of 14g 3. profuse diarrhea and stool specimen shows campylobacter 4. hard, rigid, abdomen and wbc count 22000

4 (a hard rigid abdomen indicates an inflamed peritoneum (abdominal wall cavity) resulting from an infection, which results in an elevated WBC level)

the client has been experiencing difficulty and straining when expelling feces. which intervention should the nurse discuss with the client? 1. explain some blood in the stool will be normal for the client 2. instruct the client in manual removal of feces 3. encourage the client to use a cathartic laxative on a daily basis 4. place the client on a high fiber diet

4 (a high fiber (residue) diet provides bulk for the colon to use in removing the waster products of metabolism. bulk laxatives and fiber from vegetables and bran assist the colon to work more effectively. 1. blood may indicate a hemorrhoid, but isnt normal to expel blood when having a bowel movement. 2. nurses manually remove feces, it is not a self care activity. cathartic use on a daily basis creates dependence and a narrowing of the lumen of the colon, creating a much more serious problem.)

the client developed a paralytic ileus after abdominal surgery. which intervention should the nurse include in the plan of care? 1. administer a laxative of choice 2. encourage client to increase oral fluids 3. encourage client to take deep breaths 4. maintain a patent ng tube

4 (a paralytic ileus is the absence of peristalsis; therefore, the bowel will be unable to process any oral intake. a ng tube is inserted to decompress the bowel until surgical intervention or until bowel sounds return spontaneously)

the nurse writes a psychosocial problem of risk for altered sexual functioning r/t new colostomy. which intervention should the nurse implement? 1. tell the client there should be no intimacy for at least 3 months 2. ensure the client and significant other are able to change the ostomy pouch 3. demonstrate with charts possible sexual positions for the client to assume 4. teach the client to protect the pouch from becoming dislodges during sex

4 (a pouch that becomes dislodged during the sexual act would cause embarrassment for the client, whose body image has already been dealt a blow)

the client is 2 hours pot colonoscopy. which assessment data warrant intermediate intervention by the nurse? 1. the client has a soft, nontender abdomen. 2. the client has a loose, watery stool 3. the client has hyperactive bowel sounds 4. the clients pulse is 104 and bp is 98/60

4 (bowel perforation is a potential complication of a colonoscopy. therefore, signs of hypotension- decreased bp and increased pulse- warrant immediate intervention from the nurse)

a 44 y/o client is dx with peritonitis after a small bowel obstruction. the nurse would: 1. encourage ambulation 2. place the client in a supine position 3. check the mouth for ulcerations 4. keep the client NPO

4 (food in the GI would make the obstruction worse, and the client should be prepared for surgery. bed rest should be maintained. a semi fowlers position is needed to facilitate respiratory movement.)

the client dx with IBD is prescribed sulfasaliazine (asulfidine), a sulfonamide antibiotic. which statement best describes the rationale for administering this medication? 1. it is administered rectally to help decrease colon inflammation 2. this medicaiton slows gastrointestinal motility and reduces diarrhea 3. this medication kills the bacteria causing the exacerbation 4. it acts topically on the colon mucose to decrease inflammation

4 (it acts topically on the colon mucosa to decrease inflammation: asulfidine is poorly absorbed from the gastrointestinal tract and acts topically on the colonic mucose to inhibit the inflammatory process. IBD is not caused by bacteria)

which of the following is the best site to assess for edema in a client confined to bed? 1. ankles 2. pretibial 3. hands 4. sacrum

4 (sacrum: its the most dependent area of the body for the client confined to bed rest. edema accumulates in a dependent area first)

the nurse is teaching the client dx with diverticulosis. which instruction should the nurse include in the teaching session? 1. discuss the importance of drinking 1000 mL of water daily. 2. instruct the client to exercise at least 3 times a week 3. teach the client about eating a low residue diet 4. explain the need to have daily bowel movement

4 (the client should have regular bowel movements, preferably daily. constipation may cause diverticulitis, which is a potentially life threatening complication of diverticulosis. the client should drink at least 3000 mL of water daily to help prevent constipation. the client should exercise daily to help prevent constipation, the client should eat a HIGH fiber diet to prevent constipation)

the client dx with diverticulitis is c/o severe pain in the left lower quadrant and has an oral temp of 100.6. which intervention should the nurse implement first? 1. notify the hcp 2. document the findings in the chart 3. administer an oral antipyretic 4. assess the clients abdomen

4 (the nurse should assess the client to determine if the abdomen is soft and non tender. a rigid tender abd may indicate peritonitis)

the client who has had an abdominal perineal resection is being discharged. which discharge information should the nurse teach? 1. the stoma should be a white, blue or purple color. 2. limit ambulation to prevent the pouch from coming off 3. take pain medication when the pain level is at an 8 4. empty the pouch when it is one third to one half full

4 (the pouch should be emptied when it is one third to one half full to prevent the contents from becoming too heavy for the seal to hold and to prevent leakage from occuring.)

"The nurse is caring for a patient in the emergency department with complaints of acute abdominal pain, nausea, and vomiting. When the nurse palpates the patient's left lower abdominal quadrant, the patient complains of pain in the right lower quadrant. The nurse will document this as which of the following diagnostic signs of appendicitis? "a. Rovsing sign b. referred pain c. Chvostek's sign d. rebound tenderness

A (In patients with suspected appendicitis, Rovsing sign may be elicited by palpation of the left lower quadrant, causing pain to be felt in the right lower quadrant.)

The nurse would increase the comfort of the patient with appendicitis by: "a. Having the patient lie prone b. Flexing the patient's right knee c. Sitting the patient upright in a chair d. Turning the patient onto his or her left side

B (The patient with appendicitis usually prefers to lie still, often with the right leg flexed to decrease pain.)

"A client is admitted with a diagnosis of acute appendicitis. When assessing the abdomen, the nurse would expect to find rebound tenderness at which location? a) Left lower quadrant b) Left upper quadrant c) Right upper quadrant d) Right lower quadrant

d (Right lower quadrant" Rationale: The pain of acute appendicitis localizes in the right lower quadrant (RLQ) at McBurney's point, an area midway between the umbilicus and the right iliac crest. Often, the pain is worse when manual pressure near the region is suddenly released, a condition called rebound tenderness.)

A nurse is caring for a client admitted to the hospital with a suspected diagnosis of acute appendicitis. Which laboratory results would the nurse expect to note if the client does have appendicitis?

elevated leukocyte and neutrophil