Nokea
A nurse assesses a client who is recovering from a hemorrhoidectomy that was done the day before. The nurse notes that the client has lower abdominal distention accompanied by dullness to percussion over the distended area. Which action should the nurse take?
- A. Assess the client's heart rate and blood pressure.
- B. Determine when the client last voided.
- C. Ask if the client is experiencing nausea.
- D. Auscultate all quadrants of the client's abdomen.
Correct Answer: B
Rationale: Assessment findings indicate that the client may have an over-full bladder. In the immediate postoperative period, the client may experience urinary retention. Determining when the client last voided helps confirm this.
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A nurse assesses a client with irritable bowel syndrome (IBS). Which questions should the nurse include in this client's assessment? (Select all that apply.)
- A. Which food types cause an exacerbation of symptoms?
- B. Which food types cause an amelioration of symptoms?
- C. Have you lost a significant amount of weight lately?
- D. Are your stools soft, watery, and black in color?
- E. Do you experience nausea associated with defecation?
Correct Answer: A,B,E
Rationale: The nurse should assess factors that exacerbate or ameliorate IBS symptoms, such as food, stress, and nausea related to defecation. Weight loss and black stools are not typical of IBS.
After teaching a client with irritable bowel syndrome (IBS), a nurse assesses the client's understanding. Which meal indicates the client correctly understands the dietary teaching?
- A. Ham sandwich on white bread, cup of applesauce, glass of diet cola
- B. Baked chicken with brown rice, steamed broccoli, glass of apple juice
- C. Grilled cheese sandwich, small banana, cup of tea with lemon
- D. Baked tilapia, fresh green beans, cup of coffee with low-fat milk
Correct Answer: B
Rationale: Clients with IBS are advised to eat a high-fiber diet (30 to 40 g/day), with 8 to 10 cups of liquid daily. Baked chicken with brown rice, broccoli, and apple juice has the highest fiber content. They should avoid alcohol, caffeine, and other gastric irritants.
A nurse cares for a client who has been diagnosed with a small bowel obstruction. Which assessment findings should the nurse correlate with this diagnosis? (Select all that apply.)
- A. Serum potassium of 2.5 mEq/L
- B. Loss of 15 pounds without eating
- C. Abdominal pain in upper quadrants
- D. Low-pitched bowel sounds
- E. Serum sodium of 121 mEq/L
Correct Answer: A,C,E
Rationale: Small bowel obstructions can cause fluid and electrolyte imbalances, such as low potassium and sodium, and upper quadrant pain due to obstruction. Weight loss and low-pitched bowel sounds are less specific.
A nurse teaches a client who is recovering from a colon resection. Which statement should the nurse include in this client's plan of care?
- A. Avoid heavy lifting for at least 6 weeks.
- B. Monitor your incision site for signs of infection.
- C. Resume a normal diet as tolerated.
- D. All of the above.
Correct Answer: D
Rationale: All of these statements are appropriate postoperative instructions for a colon resection. The client should avoid heavy lifting, monitor for infection, and resume a normal diet as tolerated.
A nurse cares for a middle-aged male client who has irritable bowel syndrome (IBS). The client states, 'I have changed my diet and take bulk-forming laxatives, but my symptoms have not gotten better. I heard about a drug called Amitiza. Do you think it might help?' How should the nurse respond?
- A. This drug is still in the research phase and is not available for public use yet.
- B. Unfortunately, lubiprostone is approved only for use in women.
- C. Lubiprostone works well. I will recommend this prescription to your provider.
- D. This drug should not be used with bulk-forming laxatives.
Correct Answer: B
Rationale: Lubiprostone (Amitiza) is approved only for women with IBS with constipation. Trials with male participants are needed for FDA approval in men.