Nokea
A client is to have a sigmoidoscopy in the morning. Which activity will be included in the care of this client?
- A. Give him an enema one hour before the examination.
- B. Keep him NPO for eight hours before the examination.
- C. Order a low-fat, low-residue diet for breakfast.
- D. Administer enemas until the returns are clear this evening.
Correct Answer: A
Rationale: An enema one hour before sigmoidoscopy clears the sigmoid colon for better visualization.
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The client is 6 days post—total proctocolectomy with ileostomy creation for ulcerative colitis. The client’s ileostomy is draining large amounts of liquid stool, and the client has dizziness with ambulation. Which parameters should the nurse assess immediately?
- A. Pulse rate for the last 24 hours
- B. Urine output for the last 24 hours
- C. Weight over the last 3 days
- D. Ability to move the lower extremities
- E. Temperature readings for the last 24 hours
Correct Answer: A, B, C, E
Rationale: The nurse should assess for increasing pulse rate over time because it is a sign of dehydration; large amounts of ileostomy output can result in dehydration, and the dizziness with ambulation could be from dehydration. B. The nurse should assess for decreasing urine output because it is a sign of dehydration; large amounts of ileostomy output can result in dehydration, and the dizziness with ambulation could be from dehydration. C. The nurse should assess for decreasing weight because it is a sign of dehydration; large amounts of ileostomy output can result in dehydration, and the dizziness with ambulation could be from dehydration. D. The ability to move the lower extremities is not related to dehydration. E. The nurse should assess the temperature readings because a low-grade temperature is a sign of dehydration; large amounts of ileostomy output can result in dehydration, and the dizziness with ambulation could be from dehydration.
The client recovering from acute pancreatitis who has been NPO asks the nurse, “When can I start eating again?” Which response by the nurse is most accurate?
- A. “As soon as you start to feel hungry you can begin eating.”
- B. “When I hear that your bowel sounds are active and you are passing flatus.”
- C. “When your pain is controlled and your serum lipase level has decreased.”
- D. “You will be NPO for at least more 2 weeks; oral intake stimulates the pancreas.”
Correct Answer: C
Rationale: A. Regaining appetite is a positive sign, but it must be accompanied by a decrease in pain before the client is allowed to take food orally. B. Intestinal peristalsis may be slowed due to inflammation associated with acute pancreatitis, but the return of bowel sounds and flatus is not used to determine when to begin oral intake. C. This response is correct. Once pain is controlled and the serum enzyme levels begin to decrease, the client can begin oral intake. These are signs that the pancreas is healing. D. There is no specific time limit for being NPO.
The nurse is preparing the client for a fiberoptic colonoscopy for colon polyps. Which task can be delegated to the unlicensed assistive personnel (UAP)?
- A. Administer the polyethylene glycol electrolyte lavage solution.
- B. Explain to the client why this morning's breakfast is withheld.
- C. Start an intravenous site with 0.9% normal saline fluid.
- D. Administer a cleansing enema until the return is clear.
Correct Answer: D
Rationale: Administering a cleansing enema is within the UAP’s scope with training. Administering solutions, explaining procedures, and starting IVs require RN skills.
The client diagnosed with Crohn's disease is crying and tells the nurse, 'I can't take it anymore. I never know when I will get sick and end up here in the hospital.' Which statement is the nurse's best response?
- A. I understand how frustrating this must be for you.
- B. You must keep thinking about the good things in your life.
- C. I can see you are very upset. I'll sit down and we can talk.
- D. Are you thinking about doing anything like committing suicide?
Correct Answer: C
Rationale: Acknowledging the client's distress and offering to talk provides emotional support and opens communication to address concerns. The other responses are less therapeutic, either minimizing the issue or jumping to assumptions about suicide risk.
Which assessment data indicate to the nurse the client's gastric ulcer has perforated?
- A. Complaints of sudden, sharp, substernal pain.
- B. Rigid, boardlike abdomen with rebound tenderness.
- C. Frequent, clay-colored, liquid stool.
- D. Complaints of vague abdominal pain in the right upper quadrant.
Correct Answer: B
Rationale: A rigid, boardlike abdomen with rebound tenderness indicates peritonitis, a common complication of ulcer perforation due to leakage of gastric contents into the peritoneal cavity. Substernal pain, clay-colored stools, and vague pain are less specific.