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Before undergoing a colon resection for cancer of the colon, a patient has an elevated carcinoembryonic antigen (CEA) test. Which of the following explanations should the nurse provide to the patient about this test?
- A. It confirms the diagnosis of colon cancer.
- B. It monitors the tumour status after surgery.
- C. It identifies the extent of cancer spread or metastasis.
- D. It determines the need for postoperative chemotherapy.
Correct Answer: B
Rationale: CEA is used to monitor for cancer recurrence after surgery. CEA levels do not help determine whether there is metastasis of the cancer. Confirmation of the diagnosis is made on the basis of biopsy. Chemotherapy use is based on factors other than CEA.
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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.
Which of the following nursing actions is most important to include in the plan of care for a patient who had an abdominal-perineal resection the previous day?
- A. Teach about a low-residue diet.
- B. Monitor output from the stoma.
- C. Assess the perineal drainage and incision.
- D. Encourage acceptance of the colostomy stoma.
Correct Answer: C
Rationale: Because the perineal wound is at high risk for infection, the initial care is focused on assessment and care of this wound. Teaching about diet is best done closer to discharge from the hospital. There will be very little drainage into the colostomy until peristalsis returns. The patient will be encouraged to assist with the colostomy, but this is not the highest priority in the immediate postoperative period.
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 obtaining a history for a female patient who is being evaluated for acute lower abdominal pain and vomiting. Which of the following questions is most useful in determining the cause of the patient's symptoms?
- A. Is it possible that you are pregnant?
- B. Can you tell me more about the pain?
- C. What type of foods do you usually eat?
- D. What is your usual elimination pattern?
Correct Answer: B
Rationale: A complete description of the pain provides clues about the cause of the problem. The usual diet and elimination patterns are less helpful in determining the reason for the patient's symptoms. Although the nurse should ask whether the patient is pregnant to determine whether the patient might have an ectopic pregnancy and before any radiology studies are done, this information is not the most useful in determining the cause of the pain.
During the initial postoperative assessment of a patient's stoma formed from a transverse colostomy, the stoma appearance indicates good circulation to the stoma. Which of the following actions should the nurse take based upon these findings?
- A. Document the stoma assessment
- B. Assess the stoma every 30 minutes
- C. Notify the surgeon about the stoma
- D. Place an ice pack on the stoma to reduce swelling
Correct Answer: A
Rationale: The stoma appearance indicates good circulation to the stoma. There is no indication that surgical intervention is needed or that frequent stoma monitoring is required. Swelling of the stoma is normal for 2-3 weeks after surgery, and an ice pack is not needed.