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A nurse plans care for a client with Crohn's disease who has a heavily draining fistula. Which intervention should the nurse indicate as the priority action in this client's plan of care?
- A. Low-fiber diet
- B. Skin protection
- C. Antibiotic administration
- D. Blood glucose monitoring
Correct Answer: B
Rationale: A heavily draining fistula releases caustic intestinal fluids that can cause skin breakdown or infections. Skin protection is the priority to prevent complications. Nutrition, antibiotics, and glucose monitoring are important but secondary.
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A nurse cares for a client who has a Giardia infection. Which medication should the nurse anticipate being prescribed for this client?
- A. Metronidazole (Flagyl)
- B. Ciprofloxacin (Cipro)
- C. Sulfasalazine (Azulfidine)
- D. Ceftriaxone (Rocephin)
Correct Answer: A
Rationale: Metronidazole is the drug of choice for Giardia, a parasitic infection. Ciprofloxacin and ceftriaxone treat bacterial infections, and sulfasalazine is used for ulcerative colitis or Crohn's disease, not Giardia.
A nurse cares for a client with ulcerative colitis. The client states, 'I feel like I am tied to the toilet. This disease is controlling my life.' How should the nurse respond?
- A. Let's identify stress factors that worsen your symptoms to help you gain more control.
- B. If you take the prescribed medications, you will no longer have diarrhea.
- C. To decrease distress, do not eat anything before you go out.
- D. You must take control of your life. I will consult a therapist to help.
Correct Answer: A
Rationale: Identifying stress factors that exacerbate ulcerative colitis symptoms empowers the client to manage their condition. Medications reduce but do not eliminate diarrhea, fasting is not practical, and suggesting a therapist without discussion dismisses the client's concerns.
A nurse cares for a client with a new ileostomy. The client states, 'I don't think my friends will accept me with this ostomy.' How should the nurse respond?
- A. Your friends will be happy you are alive.
- B. Tell me more about your concerns.
- C. A therapist can help you resolve your concerns.
- D. With time you will accept your new body.
Correct Answer: B
Rationale: Encouraging the client to express concerns addresses social anxiety and apprehension common with a new ostomy. Minimizing concerns, suggesting a therapist without discussion, or assuming acceptance over time are not therapeutic responses.
A nurse cares for a client who has food poisoning resulting from a Clostridium botulinum infection. Which assessment should the nurse complete first?
- A. Heart rate and rhythm
- B. Bowel sounds
- C. Urinary output
- D. Respiratory rate
Correct Answer: D
Rationale: Clostridium botulinum infection can cause respiratory failure due to neurotoxin effects. Assessing respiratory rate and oxygen saturation is the priority to detect early signs of respiratory compromise. Other assessments are important but secondary.
A nurse cares for a client who is prescribed 5 mg/kg of infliximab (Remicade) intravenously. The client weighs 110 lbs and the pharmacy supplies infliximab 100 mg/10 mL solution. How many milliliters should the nurse administer to this client? (Record your answer using a whole number)
- A. 20 mL
- B. 25 mL
- C. 30 mL
- D. 35 mL
Correct Answer: B
Rationale: The client weighs 110 lbs (50 kg). The dose is 5 mg/kg, so 5 mg/kg ? 50 kg = 250 mg. The pharmacy supplies 100 mg/10 mL, so 250 mg ÷ 100 mg/10 mL = 25 mL.