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The client with a colostomy has an order for irrigation of the colostomy. The nurse uses which solution for the irrigation?
- A. Distilled water
- B. Tap water
- C. Sterile water
- D. Lactated Ringer's
Correct Answer: B
Rationale: The correct answer is B: Tap water. Tap water is used for colostomy irrigation as it is isotonic and won't disrupt electrolyte balance. Distilled water (A) can cause electrolyte imbalances. Sterile water (C) may not be necessary, and Lactated Ringer's (D) is not typically used for colostomy irrigation.
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A nurse is performing an assessment on a client with a suspected diagnosis of acute pancreatitis. The nurse assesses the client, knowing that which of the following is a hallmark sign of this disorder?
- A. Severe abdominal pain relieved by vomiting
- B. Severe abdominal pain that is unrelieved by vomiting
- C. Hypothermia
- D. Epigastric pain radiating to the neck area
Correct Answer: B
Rationale: The correct answer is B: Severe abdominal pain that is unrelieved by vomiting. In acute pancreatitis, the pancreatic enzymes cause inflammation and damage to the pancreas, leading to severe abdominal pain that is typically constant and not relieved by vomiting. Vomiting may even worsen the pain. Other choices are incorrect because severe abdominal pain in acute pancreatitis is not relieved by vomiting (A), hypothermia is not a hallmark sign of acute pancreatitis (C), and epigastric pain radiating to the neck area is not a specific hallmark sign (D).
A client is admitted with a diagnosis of ulcerative colitis. Which of the following symptoms should the nurse expect the client to report when responding to questions about his bowel elimination pattern?
- A. Constipation.
- B. Bloody, diarrheal stools.
- C. Steatorrhea.
- D. Alternating periods of constipation and diarrhea.
Correct Answer: B
Rationale: The correct answer is B: Bloody, diarrheal stools. In ulcerative colitis, inflammation of the colon leads to symptoms such as bloody diarrhea. This occurs due to ulceration and inflammation of the colon lining. The presence of blood in the stool is a hallmark symptom of ulcerative colitis. The other choices are incorrect because:
A: Constipation is not typically associated with ulcerative colitis. It is more common in conditions like irritable bowel syndrome.
C: Steatorrhea, which is fatty, greasy stools, is not a common symptom of ulcerative colitis.
D: Alternating periods of constipation and diarrhea are more indicative of conditions like irritable bowel syndrome or functional gastrointestinal disorders, not specifically ulcerative colitis.
A nurse is providing instructions to a client who will collect a stool specimen for occult blood. The nurse instructs the client to avoid which of the following for 3 days before the collection of the stool specimen?
- A. Milk products
- B. Hard cheese
- C. Turnips
- D. Cottage cheese
Correct Answer: C
Rationale: The correct answer is C: Turnips. Turnips contain peroxidase enzymes that can cause false-positive results in occult blood tests. Therefore, the client should avoid consuming turnips for 3 days before collecting the stool specimen.
Incorrect options:
A: Milk products - Milk products do not interfere with occult blood tests.
B: Hard cheese - Hard cheese does not contain peroxidase enzymes that would affect the test results.
D: Cottage cheese - Cottage cheese also does not contain peroxidase enzymes that would interfere with the test.
Cholestyramine resin (Questran Light) is prescribed for the client with an elevated serum cholesterol level. The nurse would instruct the client to take the medication
- A. After meals.
- B. Mixed with fruit juice.
- C. Via rectal suppository.
- D. At least 3 hours before meals.
Correct Answer: B
Rationale: The correct answer is B: Mixed with fruit juice. Cholestyramine resin should be taken mixed with a liquid, such as fruit juice, to prevent esophageal irritation and improve absorption. Taking it with a meal can interfere with nutrient absorption. Taking it via rectal suppository is incorrect as it is an oral medication. Taking it at least 3 hours before meals is not necessary and may lead to decreased effectiveness. Mixing it with fruit juice helps improve tolerability and effectiveness.
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.