Nokea
A client is scheduled for an abdominal perineal resection with permanent colostomy. Which of the following measures would most likely be included in the plan for the client's preoperative preparation?
- A. Keep the client NPO for 2 days before surgery.
- B. Administer kanamycin (Kantrex) the night before surgery.
- C. Inform the client that chest tubes will be in place after surgery.
- D. Advise the client to limit activity.
Correct Answer: B
Rationale: The correct answer is B: Administer kanamycin (Kantrex) the night before surgery. This antibiotic is typically given preoperatively to reduce the risk of infection during the surgical procedure. It helps to eliminate or reduce the number of bacteria in the gastrointestinal tract, which could potentially contaminate the surgical site during the abdominal perineal resection with permanent colostomy.
A: Keeping the client NPO for 2 days before surgery is not necessary for this procedure and could lead to unnecessary dehydration and discomfort.
C: Informing the client that chest tubes will be in place after surgery is not directly related to preoperative preparation for this specific surgery.
D: Advising the client to limit activity is important for postoperative recovery, but it is not a preoperative measure specific to this surgery.
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A client with a history of gastric ulcer suddenly complains of a sharp-severe pain in the mid epigastric area, which then spreads over the entire abdomen. The client's abdomen is rigid and board-like to palpation, and the client obtains most comfort from lying in the knee-chest position. The nurse calls the physician immediately suspecting that the client is experiencing which of the following complications of peptic ulcer disease?
- A. Perforation
- B. Obstruction
- C. Hemorrhage
- D. Intractability
Correct Answer: A
Rationale: The correct answer is A: Perforation. The sudden onset of sharp-severe pain, rigidity, and board-like abdomen are classic signs of a perforated gastric ulcer. The spreading pain and relief in the knee-chest position indicate free air in the peritoneal cavity. Perforation is a serious complication requiring immediate medical attention to prevent peritonitis and sepsis.
Choice B: Obstruction is incorrect because it typically presents with a gradual onset of pain, bloating, vomiting, and inability to pass stool or gas.
Choice C: Hemorrhage is incorrect as it usually presents with symptoms like hematemesis, melena, and signs of blood loss such as hypotension and tachycardia.
Choice D: Intractability is incorrect because it refers to the condition being difficult to manage or cure, which is not the acute presentation described in the question.
A nurse is reviewing the orders of a client admitted to the hospital with a diagnosis of acute pancreatitis. Select the interventions that the nurse would expect to be prescribed for the client.
- A. Small, frequent high-calorie feedings.
- B. Meperidine (Demerol) as prescribed for pain.
- C. Place the client in a side-lying position with the head elevated 45-degrees.
- D. Administer antacids and anticholinergics to suppress gastrointestinal secretions.
Correct Answer: B
Rationale: The correct answer is B: Meperidine (Demerol) as prescribed for pain. In acute pancreatitis, pain management is crucial, and Meperidine is commonly used due to its minimal effect on the sphincter of Oddi.
Incorrect options:
A: Small, frequent high-calorie feedings can exacerbate pancreatitis by stimulating pancreatic enzyme secretion.
C: Placing the client in a side-lying position with the head elevated is not a specific intervention for pancreatitis.
D: Administering antacids and anticholinergics is not a standard treatment for pancreatitis and may not address the underlying cause of the condition.
A 30-year-old woman is admitted to the hospital with complaints of severe abdominal cramping and diarrhea. The nurse evaluates the effectiveness of the patient's intravenous therapy. Which of the following laboratory tests BEST reflects hydration status?
- A. Erythrocyte sedimentation rate.
- B. White blood cell count.
- C. Hematocrit.
- D. Serum glucose.
Correct Answer: C
Rationale: The correct answer is C: Hematocrit. Hematocrit reflects the proportion of red blood cells in the blood and can indicate hydration status. When a person is dehydrated, their blood becomes more concentrated, leading to an increase in hematocrit levels. In this case, severe abdominal cramping and diarrhea can cause dehydration, making hematocrit the best indicator of hydration status.
Explanation for other choices:
A: Erythrocyte sedimentation rate is a nonspecific marker of inflammation and not directly related to hydration status.
B: White blood cell count is an indicator of infection or inflammation, not hydration status.
D: Serum glucose levels are related to blood sugar regulation, not hydration status.
A client has a nasogastric tube inserted at the time of abdominal perineal resection with permanent colostomy. This tube will most likely be removed when the client demonstrates:
- A. Absence of nausea and vomiting.
- B. Passage of mucus from the rectum.
- C. Passage of flatus and feces from the colostomy.
- D. Absence of stomach drainage for 24 hours.
Correct Answer: C
Rationale: The correct answer is C: Passage of flatus and feces from the colostomy. This indicates that the gastrointestinal tract is functioning properly post-operatively. The nasogastric tube is typically removed once the client's bowel function has returned, as evidenced by the passage of flatus and feces from the colostomy. This indicates that the client's bowels are working and there is no longer a need for the tube to decompress the stomach. Choices A, B, and D are incorrect because the absence of nausea and vomiting, passage of mucus from the rectum, and absence of stomach drainage do not directly indicate the return of normal bowel function, which is the key factor for removing the nasogastric tube in this scenario.
Which of the following expected outcomes would be most appropriate for a client with peptic ulcer disease? The client will:
- A. verbalize absence of epigastric pain.
- B. accept the need to inject himself with vitamin B12 for the rest of his life.
- C. understand the need to increase his exercise activity.
- D. eliminate stress from his life.
Correct Answer: A
Rationale: The correct answer is A: verbalize absence of epigastric pain. This outcome is most appropriate as it directly relates to the client's condition of peptic ulcer disease. Verbalizing the absence of epigastric pain indicates that the client's ulcer is healing and symptoms are improving. It is a measurable and specific goal that reflects the client's progress in managing the disease.
Choice B is incorrect as vitamin B12 injections are not typically necessary for peptic ulcer disease. Choice C is incorrect as exercise may not directly impact the ulcer and may even exacerbate symptoms. Choice D is incorrect as eliminating stress completely is unrealistic and may not directly impact the ulcer.