Nokea
A nurse assesses a client with ulcerative colitis. Which complications are paired correctly with their physiologic processes? (Select all that apply.)
- A. Lower gastrointestinal bleeding - Erosion of the bowel wall
- B. Abscesses - Localized pockets of infection develop in the ulcerated bowel lining
- C. Toxic megacolon - Transmural inflammation resulting in pyuria and fecaluria
- D. Non-mechanical bowel obstruction - Paralysis of colon resulting from colorectal cancer
- E. Fistulas - Dilation and decreased motility caused by paralysis of the colon
Correct Answer: A,B,D
Rationale: Lower GI bleeding results from bowel wall erosion, abscesses form in ulcerated bowel lining, and non-mechanical bowel obstruction occurs due to colon paralysis from colorectal cancer. Toxic megacolon involves colon dilation, not pyuria/fecaluria, and fistulas result from transmural inflammation, not paralysis.
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A nurse assesses a client who is hospitalized with an exacerbation of Crohn's disease. Which clinical manifestation should the nurse expect to find?
- A. Positive Murphy's sign with rebound tenderness to palpation
- B. Dull, hypoactive bowel sounds in the lower abdominal quadrant
- C. High-pitched, rushing bowel sounds in the right lower quadrant
- D. Reports of abdominal cramping that is worse at night
Correct Answer: C
Rationale: High-pitched, rushing bowel sounds are expected in Crohn's disease due to narrowing of the bowel lumen. Positive Murphy's sign indicates gallbladder disease, and rebound tenderness suggests peritonitis. Dull, hypoactive bowel sounds and nightly worsening of cramping are not typical of Crohn's disease.
A nurse cares for a client who is prescribed 5 mg/kg of infliximab (Remicade) intravenously. The client weighs 110 lbs and the pharmacy supplies infliximab 100 mg/10 mL solution. How many milliliters should the nurse administer to this client? (Record your answer using a whole number)
- A. 20 mL
- B. 25 mL
- C. 30 mL
- D. 35 mL
Correct Answer: B
Rationale: The client weighs 110 lbs (50 kg). The dose is 5 mg/kg, so 5 mg/kg ? 50 kg = 250 mg. The pharmacy supplies 100 mg/10 mL, so 250 mg ÷ 100 mg/10 mL = 25 mL.
A nurse teaches a client how to avoid becoming ill with Salmonella infection again. Which statements should the nurse include in this client's teaching? (Select all that apply.)
- A. Wash your hands with hot water before eating.
- B. Cook foods thoroughly, especially poultry and eggs.
- C. Wash your hands before and after using the bathroom.
- D. Avoid eating raw or undercooked eggs and meats.
- E. Refrigerate leftovers promptly to prevent bacterial growth.
Correct Answer: B,C,D,E
Rationale: To prevent Salmonella infection, clients should cook foods thoroughly, wash hands before and after bathroom use, avoid raw or undercooked eggs and meats, and refrigerate leftovers promptly to inhibit bacterial growth. Hot water is not specifically required; soap and water are sufficient.
A nurse assesses a client who is recovering from an ileostomy placement. Which clinical manifestation should alert the nurse to urgently contact the health care provider?
- A. Pale and bluish stoma
- B. Liquid stool
- C. Ostomy pouch intact
- D. Blood-smeared output
Correct Answer: A
Rationale: A pale or bluish stoma indicates potential ischemia or poor perfusion, requiring urgent provider notification. Liquid stool and blood-smeared output are expected after ileostomy placement, and an intact pouch is normal.
A nurse plans care for a client with Crohn's disease who has a heavily draining fistula. Which intervention should the nurse indicate as the priority action in this client's plan of care?
- A. Low-fiber diet
- B. Skin protection
- C. Antibiotic administration
- D. Blood glucose monitoring
Correct Answer: B
Rationale: A heavily draining fistula releases caustic intestinal fluids that can cause skin breakdown or infections. Skin protection is the priority to prevent complications. Nutrition, antibiotics, and glucose monitoring are important but secondary.