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A patient tells the nurse, 'I have problems with constipation now that I am older, so I use a suppository every morning.' Which of the following actions should the nurse take first?
- A. Encourage the patient to increase oral fluid intake
- B. Inform the patient that a daily bowel movement is unnecessary.
- C. Assess the patient about individual risk factors for constipation.
- D. Suggest that the patient increase dietary intake of high-fibre foods.
Correct Answer: C
Rationale: The nurse's initial action should be further assessment of the patient for risk factors for constipation and for usual bowel pattern. The other actions may be appropriate but will be based on the assessment.
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The nurse is providing patient teaching about recommended dietary choices for a patient with an acute exacerbation of inflammatory bowel disease (IBD). Which of the following diet choices by the patient indicates a need for more teaching?
- A. Scrambled eggs
- B. White toast and jam
- C. Oatmeal with cream
- D. Pancakes with syrup
Correct Answer: C
Rationale: During acute exacerbations of IBD, the patient should be on a low-residue diet and avoid high-fibre foods such as whole grains. High-fat foods also may cause diarrhea in some patients. The other choices are low residue and would be appropriate for this patient.
The nurse is admitting a patient for evaluation of right lower quadrant abdominal pain accompanied by nausea and vomiting. On assessment the temperature is 37.5°C (99.5°F), heart rate 105, respiratory rate 20 and an O2 saturation of 90%. Which of the following actions should the nurse take?
- A. Check for rebound tenderness.
- B. Assist the patient to cough and deep breathe.
- C. Administer oxygen via nasal cannula.
- D. Encourage the patient to take sips of clear liquids.
Correct Answer: C
Rationale: The patient's clinical manifestations are consistent with appendicitis but the main priority is to administer oxygen as the O2 saturation is only 90%. The patient should be NPO in case immediate surgery is needed. Checking for rebound tenderness frequently is unnecessary and uncomfortable for the patient. The patient will need to know how to cough and deep breathe postoperatively, but coughing will increase pain at this time.
The nurse is caring for a patient who is incontinent of watery diarrhea and has been diagnosed with Clostridium difficile. Which of the following actions should the nurse include in the plan of care?
- A. Order a diet with no dairy products for the patient.
- B. Place the patient in a private room with contact isolation.
- C. Teach the patient about why antibiotics are not being used.
- D. Educate the patient about proper food handling and storage.
Correct Answer: B
Rationale: Because C. difficile is highly contagious, the patient should be placed in a private room and contact precautions should be used. There is no need to restrict dairy products for this type of diarrhea. Metronidazole is frequently used to treat C. difficile. Improper food handling and storage do not cause C. difficile.
The nurse is caring for a patient who has had a total proctocolectomy and permanent ileostomy who tells the nurse, 'I cannot bear to even look at the stoma. I do not think I can manage all these changes.' Which of the following actions is best?
- A. Develop a detailed written plan for ostomy care for the patient.
- B. Ask the patient more about the concerns with stoma management.
- C. Reassure the patient that care for the ileostomy will become easier.
- D. Postpone any patient teaching until the patient adjusts to the ileostomy.
Correct Answer: B
Rationale: Encouraging the patient to share concerns assists in helping the patient adjust to the body changes. Acknowledgement of the patient's feelings and concerns is important rather than offering false reassurance. Because the patient indicates that the feelings about the ostomy are the reason for the difficulty with the many changes, development of a detailed ostomy care plan will not improve the patient's ability to manage the ostomy. Although detailed ostomy teaching may be postponed, the nurse should offer teaching about some aspects of living with an ostomy.
The nurse is caring for a patient with ulcerative colitis who underwent a proctocolectomy with an ileostomy. Which of the following information should the nurse include in patient teaching?
- A. Restrict fluid intake to prevent constant liquid drainage from the stoma.
- B. Use care when eating high-fibre foods to avoid obstruction of the ileum.
- C. Irrigate the ileostomy daily.
- D. Change the pouch every day to prevent leakage of contents onto the skin.
Correct Answer: B
Rationale: High-fibre foods are introduced gradually and should be well chewed to avoid obstruction of the ileostomy. Patients with ileostomies lose the absorption of water in the colon and need to take in increased amounts of fluid. The pouch should be drained frequently but is changed every 5-7 days. The drainage from an ileostomy does not require daily irrigation.