Nokea
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.
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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.
A patient has been experiencing disconcerting GI symptoms that have been worsening in severity. Following medical assessment, the patient has been diagnosed with lactose intolerance. The nurse should recognize an increased need for what form of health promotion?
- A. Annual screening colonoscopies
- B. Adherence to recommended immunization schedules
- C. Regular blood pressure monitoring
- D. Frequent screening for osteoporosis
Correct Answer: D
Rationale: Persons with lactose intolerance often experience hypocalcemia and a consequent risk of osteoporosis related to malabsorption of calcium. Lactose intolerance does not create an increased need for screening for colorectal cancer, immunizations, or blood pressure monitoring.
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.
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 patient has been diagnosed with a small bowel obstruction and has been admitted to the medical unit. The nurses care should prioritize which of the following outcomes?
- A. Preventing infection
- B. Maintaining skin and tissue integrity
- C. Preventing nausea and vomiting
- D. Maintaining fluid and electrolyte balance
Correct Answer: D
Rationale: All of the listed focuses of care are important for the patient with a small bowel obstruction. However, the patients risk of fluid and electrolyte imbalances is an immediate threat to safety, and is a priority in nursing assessment and interventions.