Nokea
A client is found to have colon cancer. An abdominoperineal resection and colostomy are scheduled. Neomycin is ordered. The nurse explains to the client that the primary purpose for administering this drug is to:
- A. decrease peristalsis in the intestines.
- B. decrease the bacterial content in the colon.
- C. reduce inflammation of the bowel.
- D. help prevent postoperative pneumonia.
Correct Answer: B
Rationale: Neomycin, a poorly absorbed antibiotic, reduces bacterial content in the colon to prevent postoperative infections like peritonitis.
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The client has severe liver disease. Which of the following observations is most indicative of serious problems?
- A. The client has generalized urticaria.
- B. The client is 'confused' and can no longer write his name legibly.
- C. The client is jaundiced.
- D. The client has ecchymotic areas on his arms.
Correct Answer: B
Rationale: Confusion and impaired handwriting suggest hepatic encephalopathy, a serious complication of liver disease due to ammonia buildup.
The nurse is assigned to care for four clients. The nurse should plan to assess which client first?
- A. The client with ascites who is having mild dyspnea with activity
- B. The client with a peptic ulcer who now has severe vomiting
- C. The client who had a colonoscopy and is having diarrheal stools
- D. The client with Crohn’s disease who received an initial dose of certolizumab (Cimzia) and is having generalized rashes
Correct Answer: D
Rationale: D. The client with Crohn’s disease who received an initial dose of certolizumab (Cimzia) and is having generalized rashes should be attended to first. Generalized rash indicates an allergic reaction. This could develop into an anaphylactic reaction. B. The client with a peptic ulcer who now has severe vomiting should be attended to second. Vomiting in PUD may indicate a complication such as mechanical obstruction from scarring. C. The client who had a colonoscopy and is having diarrheal stools should be attended to third. Diarrhea may have been the indication for the client’s colonoscopy or a side effect of the bowel prep. A. The client with ascites who is having mild dyspnea with activity can be attended to last. The dyspnea is usually due to the enlarged abdomen.
The nurse is facilitating a support group for clients diagnosed with Crohn's disease. Which information is most important for the nurse to discuss with the clients?
- A. Discuss coping skills to assist with adaptation to lifestyle modifications.
- B. Teach about drug administration, dosages, and scheduled times.
- C. Teach dietary changes necessary to control symptoms.
- D. Explain the care of the ileostomy and necessary equipment.
Correct Answer: A
Rationale: Coping skills help clients adapt to the chronic, unpredictable nature of Crohn’s disease, addressing psychosocial needs in a support group. Medications, diet, and ileostomy care are secondary.
The client is one (1) hour post-endoscopic retrograde cholangiopancreatogram (ERCP). Which intervention should the nurse include in the plan of care?
- A. Instruct the client to cough forcefully.
- B. Encourage early ambulation.
- C. Assess for return of a gag reflex.
- D. Administer held medications.
Correct Answer: C
Rationale: ERCP involves throat anesthesia, so assessing the gag reflex ensures safe swallowing post-procedure. Coughing, ambulation, and medications are secondary.
The client two (2) hours postoperative laparoscopic cholecystectomy is complaining of severe pain in the right shoulder. Which nursing intervention should the nurse implement?
- A. Apply a heating pad to the abdomen for 15 to 20 minutes.
- B. Administer morphine sulfate intravenously after diluting with saline.
- C. Contact the surgeon for an order to x-ray the right shoulder.
- D. Apply a sling to the right arm, which was injured during surgery.
Correct Answer: B
Rationale: Right shoulder pain post-laparoscopic cholecystectomy is often referred pain from CO2 used in the procedure irritating the diaphragm. IV morphine relieves pain effectively. Heating pads, x-rays, or slings are inappropriate.