Nokea
A nurse is working with a patient who is learning to care for a continent ileostomy (Kock pouch). Following the initial period of healing, the nurse is teaching the patient how to independently empty the ileostomy. The nurse should teach the patient to do which of the following actions?
- A. Aim to eventually empty the pouch every 90 minutes.
- B. Avoid emptying the pouch until it is visibly full.
- C. Insert the catheter approximately 5 cm into the pouch.
- D. Aspirate the contents of the pouch using a 60 mL piston syringe.
Correct Answer: C
Rationale: To empty a Kock pouch, the catheter is gently inserted approximately 5 cm to the point of the valve or nipple. The length of time between drainage periods is gradually increased until the reservoir needs to be drained only every 4 to 6 hours and irrigated once each day. It is not appropriate to wait until the pouch is full, and this would not be visible. The contents of the pouch are not aspirated.
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A nurse is planning discharge teaching for a 21-year-old patient with a new diagnosis of ulcerative colitis. When planning family assessment, the nurse should recognize that which of the following factors will likely have the greatest impact on the patients coping after discharge?
- A. The familys ability to take care of the patients special diet needs
- B. The familys ability to monitor the patients changing health status
- C. The familys ability to provide emotional support
- D. The familys ability to manage the patients medication regimen
Correct Answer: C
Rationale: Emotional support from the family is key to the patients coping after discharge. A 21-year-old would be expected to self-manage the prescribed medication regimen and the family would not be primarily responsible for monitoring the patients health status. It is highly beneficial if the family is willing and able to accommodate the patients dietary needs, but emotional support is paramount and cannot be solely provided by the patient alone.
A nurse caring for a patient with colorectal cancer is preparing the patient for upcoming surgery. The nurse administers cephalexin (Keflex) to the patient and explains what rationale?
- A. To treat any undiagnosed infections
- B. To reduce intestinal bacteria levels
- C. To reduce bowel motility
- D. To reduce abdominal distention postoperatively
Correct Answer: B
Rationale: Antibiotics such as kanamycin (Kantrex), neomycin (Mycifradin), and cephalexin (Keflex) are administered orally the day before surgery to reduce intestinal bacteria. Preoperative antibiotics are not given to treat undiagnosed infections, reduce motility, or prevent abdominal distention.
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 nurse is caring for a patient who has been admitted to the hospital with diverticulitis. Which of the following would be appropriate nursing diagnoses for this patient?
- A. Acute Pain Related to Increased Peristalsis and GI Inflammation
- B. Activity Intolerance Related to Generalized Weakness
- C. Bowel Incontinence Related to Increased Intestinal Peristalsis
- D. Deficient Fluid Volume Related to Anorexia, Nausea, and Diarrhea
- E. Impaired Urinary Elimination Related to GI Pressure on the Bladder
Correct Answer: A,B,D
Rationale: Patients with diverticulitis are likely to experience pain and decreased activity levels, and are at risk of fluid volume deficit. The patient is unlikely to experience fecal incontinence and urinary function is not directly influenced.
A nursing instructor is discussing hemorrhoids with the nursing class. Which patients would the nursing instructor identify as most likely to develop hemorrhoids?
- A. A 45-year-old teacher who stands for 6 hours per day
- B. A pregnant woman at 28 weeks gestation
- C. A 37-year-old construction worker who does heavy lifting
- D. A 60-year-old professional who is under stress
Correct Answer: B
Rationale: Hemorrhoids commonly affect 50% of patients after the age of 50. Pregnancy may initiate hemorrhoids or aggravate existing ones. This is due to increased constipation during pregnancy. The significance of pregnancy is greater than that of standing, lifting, or stress in the development of hemorrhoids.