Nokea
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.
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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 is recovering from a hemorrhoidectomy. The client states, 'I need to have a bowel movement.' How should the nurse respond?
- A. I will administer a laxative to help you have a bowel movement.
- B. Let's get you to the bathroom to try and have a bowel movement.
- C. It's too soon after surgery; you should wait at least 24 hours.
- D. You should avoid straining; I'll consult with your provider about a stool softener.
Correct Answer: D
Rationale: After a hemorrhoidectomy, straining should be avoided to prevent complications. The nurse should consult with the provider about a stool softener to facilitate a bowel movement without straining.
A nurse prepares a client for a colonoscopy scheduled for tomorrow. The client states, 'My doctor told me that the fecal occult blood test was negative for colon cancer. I don't think I need the colonoscopy and would like to cancel it.' How should the nurse respond?
- A. Your doctor should not have given you that information prior to the colonoscopy.
- B. The colonoscopy is required due to the high percentage of false negatives with the blood test.
- C. A negative fecal occult blood test does not rule out the possibility of colon cancer.
- D. I will contact your doctor so that you can discuss your concerns about the procedure.
Correct Answer: C
Rationale: A negative result from a fecal occult blood test does not completely rule out the possibility of colon cancer. A colonoscopy is necessary to visualize the entire colon and take a tissue sample for biopsy.
A nurse assesses a client who is prescribed alosetron (Lotronex). Which assessment question should the nurse ask this client?
- A. Have you been experiencing any constipation?
- B. Are you eating a diet high in fiber and fluids?
- C. Do you have a history of high blood pressure?
- D. Have you noticed any changes in your vision?
Correct Answer: A
Rationale: Constipation is a life-threatening complication of alosetron. The nurse should assess the client for constipation. The other questions do not identify complications related to alosetron.
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.