HESI: Inflammatory Bowel Disease and Rationale
The nurse begins to prepare client for discharge and reinforces self-management teaching about the ileostomy for the next 2 months until the next stage of surgery is performed. The stoma drainage is currently a dark green liquid. Client asks if this is the normal drainage she should expect. 28. How should the nurse respond? A. "Yes, this is the appearance of the drainage you will always experience." B. "Your bowel movements will remain green, but they will become solid." C. "The drainage will become thicker and appear more yellow or yellow-brown." D. "Eventually you will experience normal-looking, soft brown bowel movements."
"The drainage will become thicker and appear more yellow or yellow-brown." (Once the small intestine begins to absorb increased water and sodium, the stool will become pastelike in consistency and will appear more yellow-green or yellow-brown in color.)
Immediately following the sigmoidoscopy, it is important for the nurse to assess for which indicator of a potential post-procedure complication?
Rectal bleeding. (Rectal, bleeding, abdominal distention, tenderness, or guarding may indicate perforation of the intestine.)
30. When should Jessica expect to empty her pouch? A. Anytime she has any drainage. B. When the pouch is 1/3 to 1/2 full. C. When the pouch is almost 75% full. D. Only when the pouch is completely full.
When the pouch is 1/3 to 1/2 full. (This will prevent excessive pull and pressure on the pouch system, preventing leakage.)
9. What is the nurse's best response? A. "This all seems very overwhelming right now." B. "I know you are feeling very angry about this." C. "You won't have to quit college or move home." D. "You are beginning to cope with a new situation."
"This all seems very overwhelming right now." (This is an open-ended statement that acknowledges the client's expressed feelings, leaving an opportunity for her to continue to share her feelings and concerns.)
The nurse identifies that priority outcomes for client include control of her pain and her diarrhea. She receives prescriptions for diphenoxylate PRN, prednisone, sulfasalazine, and azathioprine. Her prescription for sulfasalazine reads, "Take 1 gram three times a day." The client takes the medication at 0800, 1200, and 1800, which are her mealtimes. After 2 weeks of this regimen, she reports that her diarrhea has worsened and that she vomits frequently. What instruction should the nurse provide?
"You need to increase the length of time between each dose of the medication." (Adverse GI manifestations can increase if the dose of sulfasalazine (Azulfidine) is too large or if the doses are taken too close together. The client should be instructed to take the dose as close to an every-8-hours dosing schedule as possible.)
The nurse provides a stool specimen container and instructs client to obtain three specimens, one each on three consecutive days. Which instruction(s) are important for the nurse to provide client regarding food and fluid intake during the stool specimen collection? (Select all that apply. One, some, or all options may be correct.)
-Avoid red meat. -Do not take supplemental ascorbic acid (Vitamin C). (The ingestion of hemoglobin found in red meats may cause a false-positive test result. Therefore, it should be avoided for 3 days before starting the specimen collection. Other food products, vigorous exercise, and a variety of medications may also affect the test results. Vitamin C intake has been associated with false-negative guaiac stool specimen results.)
The TPN is available in a 1000 mL bag and is prescribed to run at 60 mL per hour. The nurse will expect to hang a new bag in approximately how many hours?________________(Enter numerical value only. If rounding is necessary, round to the whole number.) The next day, the nurse enters the client's room and notes that only 30 mL of the TPN solution is remaining. The nurse contacts the pharmacy and learns that the next bag of TPN will not be available for 2 hours.
17 Volume divided by dose = x 1000 mL divided by 60 mL per hour = 16.666 = 17 hours
The UAP submits a complaint to the supervisor, who belittles her and refuses to take action. The UAP again confides to the nurse that she believes she is being "pulled" to other units more frequently because of her complaint. The UAP states she can't afford to quit work because she is the sole provider for herself and her two children. 27. With whom should the nurse advise the UAP to collaborate? A. The local women's crisis center. B. A hospital social worker. C. The hospital medical director. D. A legal aid clinic attorney.
A legal aid clinic attorney. (An attorney is the best choice to help the UAP regarding this violation of civil rights. Other possible resources include a hospital administrator or the state board of nursing.)
The nurse anticipates that Jessica will describe her diarrhea as: A. Bloody. B. Green and frothy. C. Gray with observable fat. D. Clay-colored.
A. Bloody (Clients with ulcerative colitis may experience as many as 10-20 liquid, bloody stools per day.)
After insertion of the venous access device, client is started on a TPN solution containing 50% dextrose, amino acids, lipids, vitamins, and minerals at 60 mL/hour. The nurse obtains a fingerstick glucose level 6 hours after the TPN was started. Her blood glucose level is 215 mg/dl (11.93 mmol/L) 16. What action should the nurse take? A. Slow down the rate of infusion to 30 mL/hour. B. Call the lab to obtain a stat glucose via venipuncture. C. Add regular insulin to the infusing TPN solution. D. Administer insulin using a sliding scale protocol.
Administer insulin using a sliding scale protocol. (Because of the high dextrose content, blood glucose levels should be monitored routinely and insulin should be administered per sliding scale. To reduce the likelihood of hyperglycemia, insulin may also be added to the TPN solution in the pharmacy.)
The nurse notifies the health care provider of client's obstruction and inserts a nasogastric tube and a urinary catheter. The current IV fluid, D5 0.25% sodium chloride, is increased to 125 mL/hour through the peripheral IV. The client's next dose of IV antibiotic, which is compatible with the current IV solution, is now due to be administered. 24. What action should the nurse take? A. Administer the dose as scheduled concurrently with the IV fluids. B. Stop the IV fluids until the dose of antibiotics is administered. C. Give the dose after the first liter of IV fluids is infused. D. Hold the dose until the HCP arrives to evaluate the client
Administer the dose as scheduled concurrently with the IV fluids. (The administration of fluids and broad-spectrum antibiotics is important at this time to prevent fluid volume depletion and peritonitis.)
After client has received 10 days of TPN, the catheter site becomes infected. The HCP decides that the subclavian catheter should be removed and the tip sent to the lab for culture. IV antibiotics are prescribed, and they are to be administered through a peripheral IV. 21. In providing the care, which division of tasks is best for the nurse to assign? A. The LPN removes the subclavian catheter, with the RN supervising to ensure that sterile procedure is followed. B. After the HCP removes the sublclavian catheter, the LPN updates the plan of care, and the RN starts the new IV and antibiotics. C. After the RN removes the subclavian catheter, the UAP applies pressure to the site and covers the area with a dressing. D. After the RN removes the subclavian catheter, the LPN obtains vital signs, and the UAP transports the tip to the lab.
After the RN removes the subclavian catheter, the PN obtains vital signs, and the UAP transports the tip to the lab.
The client's symptoms are managed for the next year, and she is able to gradually add many foods to her diet, finding that only alcohol, fresh fruits and vegetables, excessively greasy and spicy foods, and caffeine produce significant diarrhea. However, during her senior year in college, a number of stressful life events occur, including the death of her father and her application to graduate school. Following graduation, she reports severe, uncontrolled diarrhea that has been ongoing for the last 2 months. She is pale and dyspneic with mild exertion and reports constant fatigue and abdominal discomfort. She is hospitalized for an acute exacerbation of the ulcerative colitis. The client's hemoglobin and hematocrit are low. 14. Which additional serum lab value best reflects nutritional malabsorption? A. Albumin 1.5 g/dL. B. Calcium 8.5 mg/dL. C. BUN 20.0 mg/dL. D. Sodium 148.0 mEq/L.
Albumin 1.5 g/dL (15 g/L). (This value is significantly lower than normal values (3.5-5.0 g/dL in an adult), which is most likely the result of malnutrition.)
13. Client initially follows a low-fiber, low-lactose diet. To maintain this diet, which snack choice is best for the client? A. Butter-free popcorn and a cola. B. An apple and flavored water. C. Nachos and light beer. D. Angel food cake and cranberry juice.
Angel food cake and cranberry juice. (Juices are acceptable on a low-fiber diet, as long as they are strained or pulp-free.)
Because rectal bleeding is a common finding in ulcerative colitis, which additional information is important for the nurse to obtain from the client?
B. Fatigued or light-headed. (Continuous rectal bleeding will result in anemia, causing the client to feel fatigued, dizzy, light-headed, and weak.)
The female unlicensed assistive personnel (UAP) assisting with client's care confides to the nurse on the unit that another hospital employee has made numerous sexual advances to her despite being asked to stop. 25. The nurse recognizes that the UAP is protected under what legal statute? A. Civil Rights Legislation. B. State Nurse Practice Act. C. Joint Commission Accreditation Standards. D. Health Information Privacy Protection Act.
Civil Rights Legislation. (Workplace harassment is a violation of the UAP's civil rights.)
23. The nurse expects to alter client's oral intake in what way? A. Client should be NPO. B. Client should be given clear liquids only. C. Client should be given full liquids only. D. Client should be encouraged to eat any foods she can tolerate.
Client should be NPO. (Toxic megacolon may result in bowel obstruction and intestinal perforation; therefore, the nurse should keep the client NPO and expect to insert a nasogastric tube.)
11. Which assessment finding indicates that the diphenoxylate (Lomotil) is having the desired effect? A. Reported decrease in abdominal pain. B. No evidence of blood in the stool. C. Increase in bowel sound activity. D. Decreased number of bowel movements.
Decreased number of bowel movements.. (Diphenoxylate (Lomotil) is an antidiarrheal medication. Therefore, the best measure of the effectiveness of the medication is assessment of the number of bowel movements. Diphenoxylate (Lomotil) should be used with extreme caution for clients with ulcerative colitis because excessive use may result in colonic dilatation, causing additional problems such as toxic megacolon.)
6. What instruction should the nurse provide to a client who just completed a barium enema? A. Remain NPO for 24 hours. B. Limit fluid intake. C. Resume normal fluid intake. D. Drink extra fluids.
Drink extra fluids. (Extra fluids are important to help flush out the barium and prevent constipation and bowel obstruction.)
The next day, the nurse enters client's room and notes that only 30 mL of the TPN solution is remaining. The nurse contacts the pharmacy and learns that the next bag of TPN will not be available for 2 hours. 19. What action should the nurse take after the remaining TPN has infused? A. Apply a lock and flush the line with a heparin sodium flush solution. B. Hang a 500 ml bag of normal saline at a KVO rate. C. Hang a liter of 10% dextrose in water at the same rate of infusion. D. Hang a liter of Lactated Ringer's solution at the same rate of infusion.
Hang a liter of 10% dextrose in water (D10W) at the same rate of infusion. (This IV solution contains a dextrose concentration most similar to the TPN solution, which will help reduce the risk of hypoglycemia.)
26. What action should the nurse take? A. Verbally warn the other members of the nursing staff to avoid the alleged offender. B. Assist the UAP to confront the offender with tape-recorded proof of the harassment. C. Instruct the UAP to document all of the alleged offenses in writing and submit a copy to the supervisor. D. Advise the UAP to request a transfer to a different area of the hospital to avoid further confrontation.
Instruct the UAP to document all of the alleged offenses in writing and submit a copy to the supervisor. (Written documentation should be submitted to an individual with the authority to take further action. Information should include the conversation and action of the offender, any witnesses to the event, and the action and the response of the UAP.)
After the healthcare provider (HCP) explains the diagnosis to client, and the necessary treatment, the nurse observes that client is visibly upset and that she is trying to refrain from crying. When the nurse sits down next to the client she says her life is over and she will have to quit college and move home with her parents to let them take care of her. The client also states that her boyfriend won't want to spend time with someone who has diarrhea all the time. In responding to client, the nurse recognizes that her remarks reflect which of Erikson's developmental stages?
Intimacy versus isolation. (Young adulthood, between the ages of 18 and 35 years, is seen by Erikson as the developmental stage in which a priority concern is the maturing relationship of oneself to surrounding social systems. A major life event can greatly impact how a young adult relates to others.)
The nurse reviews the instructions for each of these medications with the client. What instruction is most important to include when teaching Jessica about the prednisone (Deltasone)? A. Urine may appear concentrated or reddish-orange in color. B. Take the daily dose at bedtime to avoid daytime drowsiness. C.Cover exposed skin when spending time in direct sunlight. D. Monitor mouth sores for white patches or increased discomfort.
Monitor mouth sores for white patches or increased discomfort. (The client may develop mouth sores as a manifestation of her ulcerative colitis. Corticosteroids, such as prednisone (Deltasone), have antiinflammatory and immunosuppressive effects that increase the risk for infection and may also mask signs of infection, so this places the client at risk for the development of an oral Candida infection. She should be instructed to report any signs of infection, including mouth sores with white patches and increasing discomfort.)
Client is placed on bowel rest, and she agrees that total parenteral nutrition (TPN) should be started. 15. Since the course of TPN treatment will last about 10 days, the nurse plans to prepare the client for the insertion of which access device? A. Percutaneous endoscopic gastrostomy. B. Implanted port below the clavicle. C. Peripheral IV in the antecubital fossa. D. Multi-lumen subclavian catheter.
Multi-lumen subclavian catheter. (A subclavian catheter provides access to a large, central vein, which will tolerate the hyperosmotic solution of TPN. These catheters are appropriate for short-term use, such as the 10-day course of treatment anticipated for the client.)
In developing client's plan of care, the nurse recognizes that a priority problem is an increased risk for developing an infection. 20. To ensure that the client remains free from infection, which responsibility is best to delegate to an unlicensed assistive personnel (UAP)? A. Teach the client about the signs of infection that should be reported. B. Observe the catheter insertion site for inflammation. C. Obtain and record vital signs every 4 hours. D. Clean the catheter insertion site every 72 hours.
Obtain and record vital signs every 4 hours. (This is a task that falls within the responsibilities of the UAP. Remember, it is the responsibility of the nurse to analyze the vital signs. UAP responsibilities are limited to those within the implementation phase of the nursing process.)
29. To ensure the best skin protection around the stoma, the nurse should instruct Jessica to use what type of product? A. Hydrogel dressing. B. Skin foam with Vitamins A and E. C. Transparent film dressing. D. Pectin-based solid skin barrier.
Pectin-based solid skin barrier. (Ileostomy drainage contains enzymes that can be very damaging to the skin, so a solid skin barrier should be used at all times to protect the skin around the stoma.)
Which medication that client is receiving is most likely to contribute to her increased blood glucose level? A. Azathioprine (Imuran). B. Diphenoxylate (Lomotil). C. Prednisone (Deltasone). D. Sulfasalazine (Azulfidine).
Prednisone. (Prednisone (Deltasone) is a glucocorticoid, which may increase serum glucose.)
Client develops a fever and tachycardia. She complains of abdominal cramping, and the nurse palpates an abdominal mass over the area of the transverse colon. Client seems restless and confused. 22. The nurse recognizes this complication of ulcerative colitis as: A. Tenesmus. B. Toxic megacolon. C. Carcinoma. D. Rectal fistula.
Toxic megacolon. (This massive dilatation of the colon can result in intestinal perforation and peritonitis if untreated.)
Client has no other GI symptoms at the present time. She does report that her body is stiff and aching when she rises in the morning, for which she takes a non-steroidal medication to help relieve the pain. What is the nurse's best response to this information?
Ulcerative colitis can cause problems in areas other than the colon. (Clients with moderate to extensive ulcerative colitis can experience extraintestinal complications. Some of the common manifestations affect the large joints with symptoms of arthritis and the eyes with symptoms such as blurred vision and light sensitivity (photophobia).)
Client is scheduled for a flexible sigmoidoscopy and a barium enema. Which explanation of the procedure for the barium enema should the nurse provide?
X-ray is used to visualize the large intestine after barium is instilled. (A barium enema involves a series of x-rays taken to visualize the colon. These x-rays are taken after barium is instilled into the colon through a rectal catheter.)
