Nokea
A nurse assessing a client with colorectal cancer auscultates high-pitched bowel sounds and notes visible peristaltic waves. Which action should the nurse take next?
- A. Ask if the client is experiencing pain in the right shoulder.
- B. Perform a rectal examination and assess for polyps.
- C. Contact the provider and recommend computed tomography.
- D. Administer a laxative to increase bowel movement activity.
Correct Answer: C
Rationale: The presence of visible peristaltic waves, accompanied by high-pitched or tingling bowel sounds, is indicative of a partial obstruction caused by the tumor. The nurse should contact the provider and recommend a computed tomography scan for further diagnostic testing.
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A nurse cares for a client who states, 'My husband is repulsed by my colostomy and refuses to be intimate with me.' How should the nurse respond?
- A. Let's discuss ways to help you and your husband address these concerns together.
- B. You could try to wear longer lingerie that will better hide the ostomy appliance.
- C. You should empty the pouch first so it will be less noticeable for your husband.
- D. If you are not careful, you can hurt the ostomy if you engage in sexual activity.
Correct Answer: A
Rationale: The nurse should collaborate with the client and her husband, possibly involving an ostomy nurse, to address intimacy concerns. The other options either minimize the issue or provide inaccurate information.
A nurse plans care for a client who is recovering from an inguinal hernia repair. Which interventions should the nurse include in this client's plan of care? (Select all that apply.)
- A. Encouraging ambulation three times a day
- B. Encouraging normal urination
- C. Encouraging deep breathing and coughing
- D. Encouraging the client to ambulate
- E. Forcefully reducing the hernia
Correct Answer: A,B,D
Rationale: Postoperative care includes encouraging ambulation and normal urination to promote recovery. Coughing is avoided to prevent strain on the repair, and forceful reduction is not appropriate.
A nurse cares for a client who had a colostomy placed in the ascending colon 2 weeks ago. The client states, 'The stool in my pouch is still liquid.' How should the nurse respond?
- A. The stool will always be liquid with this type of colostomy.
- B. Eating additional fiber will bulk up your stool and decrease diarrhea.
- C. The stool will become firmer over the next couple of weeks.
- D. This is abnormal. I will contact your health care provider.
Correct Answer: A
Rationale: Stool from an ascending colostomy remains liquid because there is little large bowel to reabsorb liquid. This is expected and not abnormal, and neither fiber nor time will change this.
A nurse assesses a client who is prescribed 5-fluorouracil (5-FU) chemotherapy intravenously for the treatment of colon cancer. Which assessment finding should alert the nurse to contact the health care provider?
- A. White blood cell (WBC) count of 1500/mm3
- B. Fatigue
- C. Nausea and diarrhea
- D. Mucositis and oral ulcers
Correct Answer: A
Rationale: A WBC count of 1500/mm3 is significantly below the normal range (5000-10,000/mm3), indicating a high risk for infection. The provider should be notified immediately, as chemotherapy may need to be delayed.
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.