Nokea
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.
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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 assesses a client who is recovering from an ileostomy placement. Which clinical manifestation should alert the nurse to urgently contact the health care provider?
- A. Pale and bluish stoma
- B. Liquid stool
- C. Ostomy pouch intact
- D. Blood-smeared output
Correct Answer: A
Rationale: A pale or bluish stoma indicates potential ischemia or poor perfusion, requiring urgent provider notification. Liquid stool and blood-smeared output are expected after ileostomy placement, and an intact pouch is normal.
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.
After teaching a client who has a new colostomy, the nurse provides feedback based on the client's ability to complete self-care activities. Which statement should the nurse include in this feedback?
- A. I realize that you had a tough time today, but it will get easier with practice.
- B. You cleared the stoma well. Now you need to practice putting on the appliance.
- C. You seem to understand what I taught you today. What else can I help you with?
- D. You seem to understand. Do you want your daughter to care for your ostomy?
Correct Answer: B
Rationale: Feedback should be objective and constructive, acknowledging what was done well (clearing the stoma) and identifying areas for improvement (applying the appliance). General reassurance, vague inquiries, or suggesting someone else manage the ostomy are not constructive.
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.