Nokea
A nurse is assessing a patients stoma on postoperative day 3. The nurse notes that the stoma has a shiny appearance and a bright red color. How should the nurse best respond to this assessment finding?
- A. Irrigate the ostomy to clear a possible obstruction.
- B. Contact the primary care provider to report this finding.
- C. Document that the stoma appears healthy and well perfused.
- D. Document a nursing diagnosis of Impaired Skin Integrity.
Correct Answer: C
Rationale: A healthy, viable stoma should be shiny and pink to bright red. This finding does not indicate that the stoma is blocked or that skin integrity is compromised.
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A patient with a diagnosis of colon cancer is 2 days postoperative following bowel resection and anastomosis. The nurse has planned the patients care in the knowledge of potential complications. What assessment should the nurse prioritize?
- A. Close monitoring of temperature
- B. Frequent abdominal auscultation
- C. Assessment of hemoglobin, hematocrit, and red blood cell levels
- D. Palpation of peripheral pulses and leg girth
Correct Answer: B
Rationale: After bowel surgery, it is important to frequently assess the abdomen, including bowel sounds and abdominal girth, to detect bowel obstruction. The resumption of bowel motility is a priority over each of the other listed assessments, even though each should be performed by the nurse.
An adult patient has been diagnosed with diverticular disease after ongoing challenges with constipation. The patient will be treated on an outpatient basis. What components of treatment should the nurse anticipate?
- A. Anticholinergic medications
- B. Increased fiber intake
- C. Enemas on alternating days
- D. Reduced fat intake
- E. Fluid reduction
Correct Answer: B,D
Rationale: Patients whose diverticular disease does not warrant hospital treatment often benefit from a high-fiber, low-fat diet. Neither enemas nor anticholinergics are indicated, and fluid intake is encouraged.
A patients large bowel obstruction has failed to resolve spontaneously and the patients worsening condition has warranted admission to the medical unit. Which of the following aspects of nursing care is most appropriate for this patient?
- A. Administering bowel stimulants as ordered
- B. Administering bulk-forming laxatives as ordered
- C. Performing deep palpation as ordered to promote peristalsis
- D. Preparing the patient for surgical bowel resection
Correct Answer: D
Rationale: The usual treatment for a large bowel obstruction is surgical resection to remove the obstructing lesion. Administration of laxatives or bowel stimulants are contraindicated if the bowel is obstructed. Palpation would be painful and has no therapeutic benefit.
The nurse is providing care for a patient whose inflammatory bowel disease has necessitated hospital treatment. Which of the following would most likely be included in the patients medication regimen?
- A. Anticholinergic medications 30 minutes before a meal
- B. Antiemetics on a PRN basis
- C. Vitamin B12 injections to prevent pernicious anemia
- D. Beta adrenergic blockers to reduce bowel motility
Correct Answer: A
Rationale: The nurse administers anticholinergic medications 30 minutes before a meal as prescribed to decrease intestinal motility and administers analgesics as prescribed for pain. Antiemetics, vitamin B12 injections, and beta blockers do not address the signs, symptoms, or etiology of inflammatory bowel disease.
A patient is admitted to the medical unit with a diagnosis of intestinal obstruction. When planning this patients care, which of the following nursing diagnoses should the nurse prioritize?
- A. Ineffective Tissue Perfusion Related to Bowel Ischemia
- B. Imbalanced Nutrition: Less Than Body Requirements Related to Impaired Absorption
- C. Anxiety Related to Bowel Obstruction and Subsequent Hospitalization
- D. Impaired Skin Integrity Related to Bowel Obstruction
Correct Answer: A
Rationale: When the bowel is completely obstructed, the possibility of strangulation and tissue necrosis (i.e., tissue death) warrants surgical intervention. As such, this immediate physiologic need is a nursing priority. Nutritional support and management of anxiety are necessary, but bowel ischemia is a more immediate threat. Skin integrity is not threatened.