Nokea
A 35-year-old male patient presents at the emergency department with symptoms of a small bowel obstruction. In collaboration with the primary care provider, what intervention should the nurse prioritize?
- A. Insertion of a nasogastric tube
- B. Insertion of a central venous catheter
- C. Administration of a mineral oil enema
- D. Administration of a glycerin suppository and an oral laxative
Correct Answer: A
Rationale: Decompression of the bowel through a nasogastric tube is necessary for all patients with small bowel obstruction. Peripheral IV access is normally sufficient. Enemas, suppositories, and laxatives are not indicated if an obstruction is present.
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A nurse is working with a patient who is learning to care for a continent ileostomy (Kock pouch). Following the initial period of healing, the nurse is teaching the patient how to independently empty the ileostomy. The nurse should teach the patient to do which of the following actions?
- A. Aim to eventually empty the pouch every 90 minutes.
- B. Avoid emptying the pouch until it is visibly full.
- C. Insert the catheter approximately 5 cm into the pouch.
- D. Aspirate the contents of the pouch using a 60 mL piston syringe.
Correct Answer: C
Rationale: To empty a Kock pouch, the catheter is gently inserted approximately 5 cm to the point of the valve or nipple. The length of time between drainage periods is gradually increased until the reservoir needs to be drained only every 4 to 6 hours and irrigated once each day. It is not appropriate to wait until the pouch is full, and this would not be visible. The contents of the pouch are not aspirated.
During a patients scheduled home visit, an older adult patient has stated to the community health nurse that she has been experiencing hemorrhoids of increasing severity in recent months. The nurse should recommend which of the following?
- A. Regular application of an OTC antibiotic ointment
- B. Increased fluid and fiber intake
- C. Daily use of OTC glycerin suppositories
- D. Use of an NSAID to reduce inflammation
Correct Answer: B
Rationale: Hemorrhoid symptoms and discomfort can be relieved by good personal hygiene and by avoiding excessive straining during defecation. A high-residue diet that contains fruit and bran along with an increased fluid intake may be all the treatment that is necessary to promote the passage of soft, bulky stools to prevent straining. Antibiotics, regular use of suppositories, and NSAIDs are not recommended, as they do not address the etiology of the health problem.
A patient with a diagnosis of colon cancer is 2 days postoperative following bowel resection and anastomosis. The nurse has planned the patients care in the knowledge of potential complications. What assessment should the nurse prioritize?
- A. Close monitoring of temperature
- B. Frequent abdominal auscultation
- C. Assessment of hemoglobin, hematocrit, and red blood cell levels
- D. Palpation of peripheral pulses and leg girth
Correct Answer: B
Rationale: After bowel surgery, it is important to frequently assess the abdomen, including bowel sounds and abdominal girth, to detect bowel obstruction. The resumption of bowel motility is a priority over each of the other listed assessments, even though each should be performed by the nurse.
A nurse is planning discharge teaching for a 21-year-old patient with a new diagnosis of ulcerative colitis. When planning family assessment, the nurse should recognize that which of the following factors will likely have the greatest impact on the patients coping after discharge?
- A. The familys ability to take care of the patients special diet needs
- B. The familys ability to monitor the patients changing health status
- C. The familys ability to provide emotional support
- D. The familys ability to manage the patients medication regimen
Correct Answer: C
Rationale: Emotional support from the family is key to the patients coping after discharge. A 21-year-old would be expected to self-manage the prescribed medication regimen and the family would not be primarily responsible for monitoring the patients health status. It is highly beneficial if the family is willing and able to accommodate the patients dietary needs, but emotional support is paramount and cannot be solely provided by the patient alone.
A patients colorectal cancer has necessitated a hemicolectomy with the creation of a colostomy. In the 4 days since the surgery, the patient has been unwilling to look at the ostomy or participate in any aspects of ostomy care. What is the nurses most appropriate response to this observation?
- A. Ensure that the patient knows that he or she will be responsible for care after discharge.
- B. Reassure the patient that many people are fearful after the creation of an ostomy.
- C. Acknowledge the patients reluctance and initiate discussion of the factors underlying it.
- D. Arrange for the patient to be seen by a social worker or spiritual advisor.
Correct Answer: C
Rationale: If the patient is reluctant to participate in ostomy care, the nurse should attempt to dialogue about this with the patient and explore the factors that underlie it. It is presumptive to assume that the patients behavior is motivated by fear. Assessment must precede referrals and emphasizing the patients responsibilities may or may not motivate the patient.