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After teaching a client who has a femoral hernia, the nurse assesses the client's understanding. Which statement indicates the client needs additional teaching related to the proper use of a truss?
- A. I will put on the truss before I go to bed each night.
- B. I will place some padding under the truss to avoid skin irritation.
- C. The truss will help my hernia because I can't have surgery.
- D. If I have abdominal pain, I'll let my health care provider know right away.
Correct Answer: A
Rationale: The client should be instructed to apply the truss before arising, not before going to bed at night. The other statements show an accurate understanding of using a truss.
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A nurse teaches a client who is recovering from a colon resection. Which statement should the nurse include in this client's plan of care?
- A. Avoid heavy lifting for at least 6 weeks.
- B. Monitor your incision site for signs of infection.
- C. Resume a normal diet as tolerated.
- D. All of the above.
Correct Answer: D
Rationale: All of these statements are appropriate postoperative instructions for a colon resection. The client should avoid heavy lifting, monitor for infection, and resume a normal diet as tolerated.
A nurse cares for a client who had a colostomy placed in the ascending colon 2 weeks ago. The client states, 'The stool in my pouch is still liquid.' How should the nurse respond?
- A. The stool will always be liquid with this type of colostomy.
- B. Eating additional fiber will bulk up your stool and decrease diarrhea.
- C. The stool will become firmer over the next couple of weeks.
- D. This is abnormal. I will contact your health care provider.
Correct Answer: A
Rationale: Stool from an ascending colostomy remains liquid because there is little large bowel to reabsorb liquid. This is expected and not abnormal, and neither fiber nor time will change this.
After teaching a client with irritable bowel syndrome (IBS), a nurse assesses the client's understanding. Which meal indicates the client correctly understands the dietary teaching?
- A. Ham sandwich on white bread, cup of applesauce, glass of diet cola
- B. Baked chicken with brown rice, steamed broccoli, glass of apple juice
- C. Grilled cheese sandwich, small banana, cup of tea with lemon
- D. Baked tilapia, fresh green beans, cup of coffee with low-fat milk
Correct Answer: B
Rationale: Clients with IBS are advised to eat a high-fiber diet (30 to 40 g/day), with 8 to 10 cups of liquid daily. Baked chicken with brown rice, broccoli, and apple juice has the highest fiber content. They should avoid alcohol, caffeine, and other gastric irritants.
A nurse assesses clients for the risk of colorectal cancer. Which client has the highest risk for colorectal cancer?
- A. A 37-year-old who drinks eight cups of coffee daily
- B. A 60-year-old lawyer who works long hours
- C. A 45-year-old with irritable bowel syndrome
- D. A 70-year-old who eats a high-fat diet
Correct Answer: D
Rationale: Colorectal cancer is rare before the age of 40, but its incidence increases rapidly with advancing age. A high-fat diet also increases the risk for colorectal cancer. Coffee intake, IBS, and a heavy workload do not increase the risk.
A nurse assesses a client who is recovering from a hemorrhoidectomy that was done the day before. The nurse notes that the client has lower abdominal distention accompanied by dullness to percussion over the distended area. Which action should the nurse take?
- A. Assess the client's heart rate and blood pressure.
- B. Determine when the client last voided.
- C. Ask if the client is experiencing nausea.
- D. Auscultate all quadrants of the client's abdomen.
Correct Answer: B
Rationale: Assessment findings indicate that the client may have an over-full bladder. In the immediate postoperative period, the client may experience urinary retention. Determining when the client last voided helps confirm this.