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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.
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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.
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 client who has a family history of colon cancer. The client states, 'My father and my brother had colon cancer. What is the chance that I will get cancer?' How should the nurse respond?
- A. If you eat a low-fat and low-fiber diet, your chances decrease significantly.
- B. There's no way to predict your individual risk with certainty.
- C. Preemptive surgery and chemotherapy will remove cancer cells and prevent cancer.
- D. You should have a colonoscopy more frequently to identify abnormal polyps early.
Correct Answer: D
Rationale: A family history of colon cancer increases risk, so frequent colonoscopies are recommended to detect abnormal polyps early, improving outcomes through early intervention.
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.
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.