Nokea
A nurse reviews the chart of a client who has Crohn's disease and a draining fistula. Which documentation should alert the nurse to urgently contact the provider for additional prescriptions?
- A. Serum potassium of 2.6 mEq/L
- B. Client ate 25% of breakfast meal
- C. White blood cell count of 8200/mm³
- D. Client's weight decreased by 3 pounds
Correct Answer: A
Rationale: A serum potassium level of 2.6 mEq/L is critically low and can lead to serious dysrhythmias, requiring urgent intervention. A normal white blood cell count (8200/mm³) does not warrant immediate action. Reduced meal intake and weight loss are concerning but less urgent than hypokalemia.
You may also like to solve these questions
After teaching a client who is prescribed adalimumab (Humira) for severe ulcerative colitis, the nurse assesses the client's understanding. Which statement by the client indicates a need for additional teaching?
- A. I will avoid large crowds and people who are sick.
- B. I will take this medication with my breakfast each morning.
- C. Nausea and vomiting are common side effects of this drug.
- D. I must wash my hands after I play with my dog.
Correct Answer: B
Rationale: Adalimumab (Humira) is administered via subcutaneous injection, not orally with meals. Avoiding crowds and sick individuals, recognizing nausea and vomiting as side effects, and practicing good hand hygiene are correct actions, as adalimumab causes immune suppression.
After teaching a client with an anal fissure, a nurse assesses the client's understanding. Which client actions indicate that the client correctly understands the teaching? (Select all that apply.)
- A. Taking a warm sitz bath several times each day
- B. Utilizing a daily enema to prevent constipation
- C. Using bulk-producing agents to aid elimination
- D. Taking a laxative each morning
- E. Using anti-inflammatory suppositories
Correct Answer: A,C,E
Rationale: Warm sitz baths, bulk-producing agents (e.g., psyllium), and anti-inflammatory suppositories help manage anal fissures by reducing irritation, promoting soft stools, and decreasing inflammation. Daily enemas and morning laxatives are not recommended, as they may cause dependency or irritation.
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.
A nurse assesses a client with ulcerative colitis. Which complications are paired correctly with their physiologic processes? (Select all that apply.)
- A. Lower gastrointestinal bleeding - Erosion of the bowel wall
- B. Abscesses - Localized pockets of infection develop in the ulcerated bowel lining
- C. Toxic megacolon - Transmural inflammation resulting in pyuria and fecaluria
- D. Non-mechanical bowel obstruction - Paralysis of colon resulting from colorectal cancer
- E. Fistulas - Dilation and decreased motility caused by paralysis of the colon
Correct Answer: A,B,D
Rationale: Lower GI bleeding results from bowel wall erosion, abscesses form in ulcerated bowel lining, and non-mechanical bowel obstruction occurs due to colon paralysis from colorectal cancer. Toxic megacolon involves colon dilation, not pyuria/fecaluria, and fistulas result from transmural inflammation, not paralysis.
A nurse teaches a client how to avoid becoming ill with Salmonella infection again. Which statements should the nurse include in this client's teaching? (Select all that apply.)
- A. Wash your hands with hot water before eating.
- B. Cook foods thoroughly, especially poultry and eggs.
- C. Wash your hands before and after using the bathroom.
- D. Avoid eating raw or undercooked eggs and meats.
- E. Refrigerate leftovers promptly to prevent bacterial growth.
Correct Answer: B,C,D,E
Rationale: To prevent Salmonella infection, clients should cook foods thoroughly, wash hands before and after bathroom use, avoid raw or undercooked eggs and meats, and refrigerate leftovers promptly to inhibit bacterial growth. Hot water is not specifically required; soap and water are sufficient.