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A client had an abdominal perineal resection with a colostomy 4 days ago and is ready for discharge. Which of the following would be an appropriate expected outcome at this point?
- A. The client maintains a high-fiber diet.
- B. The client discusses concerns about his sexual functioning.
- C. The client maintains bedrest.
- D. The client limits fluid intake to 1000 ml/day.
Correct Answer: B
Rationale: The correct answer is B because discussing concerns about sexual functioning is an appropriate expected outcome at this point. After an abdominal perineal resection with a colostomy, it is important for the client to address any concerns related to sexual functioning as it can impact their quality of life.
A: The client maintaining a high-fiber diet is not the most appropriate expected outcome at this point as it may be too soon after surgery to focus solely on dietary adjustments.
C: The client maintaining bedrest is not appropriate as early mobilization is usually encouraged after surgery to prevent complications.
D: Limiting fluid intake to 1000 ml/day is not recommended as adequate hydration is crucial for recovery post-surgery.
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The client with cirrhosis has ascites and excess fluid volume. Which measure will the nurse include in the plan of care for this client?
- A. Increase the amount of sodium in the diet.
- B. Limit the amount of fluids consumed.
- C. Encourage frequent ambulation.
- D. Administer magnesium antacids.
Correct Answer: B
Rationale: The correct answer is B: Limit the amount of fluids consumed. In cirrhosis with ascites and excess fluid volume, limiting fluid intake helps reduce fluid overload and prevent further accumulation of fluid in the body. Excess fluid can worsen ascites, leading to complications like respiratory distress and electrolyte imbalances. Increasing sodium intake (A) would worsen fluid retention. Encouraging ambulation (C) is important but not directly related to managing ascites. Administering magnesium antacids (D) is not necessary for addressing fluid volume excess.
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.
Which nursing measure would be most effective in helping the client cough and deep breathe after a cholecystectomy?
- A. Having the client take rapid, shallow breaths to decrease pain.
- B. Having the client lay on the left side while coughing and deep breathing.
- C. Teaching the client to use a folded blanket or pillow to splint the incision.
- D. Withholding pain medication so the client can be alert enough to follow the nurse's instructions.
Correct Answer: C
Rationale: The correct answer is C: Teaching the client to use a folded blanket or pillow to splint the incision. This measure helps support the incision site, reducing pain during coughing and deep breathing. Splinting the incision promotes effective coughing and deep breathing post-surgery, aiding in lung expansion and preventing complications like atelectasis.
Explanation of why other choices are incorrect:
A: Having the client take rapid, shallow breaths to decrease pain is incorrect as it can lead to inadequate lung expansion and retention of secretions.
B: Having the client lay on the left side while coughing and deep breathing is incorrect as it does not directly support the incision site and may not be as effective in reducing pain.
D: Withholding pain medication so the client can be alert enough to follow the nurse's instructions is incorrect as pain management is crucial post-surgery for comfort and optimal recovery.
After gastric resection surgery, which of the following signs and symptoms would alert the nurse to the development of a leaking anastomosis?
- A. Pain, fever, and abdominal rigidity.
- B. Diarrhea with fat in the stool.
- C. Palpitations, pallor, and diaphoresis after eating.
- D. Feelings of fullness and nausea after eating.
Correct Answer: A
Rationale: Rationale for choice A: Pain, fever, and abdominal rigidity are classic signs of a leaking anastomosis after gastric resection surgery. Pain indicates inflammation, fever suggests infection, and abdominal rigidity points to peritonitis. These symptoms are indicative of a surgical complication that requires immediate attention to prevent further complications like sepsis.
Summary of other choices:
B: Diarrhea with fat in the stool is more indicative of malabsorption issues, such as pancreatic insufficiency, rather than a leaking anastomosis.
C: Palpitations, pallor, and diaphoresis after eating are more suggestive of cardiovascular issues or anxiety rather than a leaking anastomosis.
D: Feelings of fullness and nausea after eating are common postoperative symptoms and do not specifically indicate a leaking anastomosis.
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.