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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.
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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 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 who has a large bowel obstruction that occurred as a result of diverticulosis. Which of the following symptoms should the nurse monitor for when assessing the patient?
- A. Referred back pain
- B. Metabolic alkalosis
- C. Projectile vomiting
- D. Abdominal distension
Correct Answer: D
Rationale: Abdominal distension is seen in lower intestinal obstruction. Metabolic alkalosis is common in high intestinal obstruction because of the loss of HCl acid from vomiting. Referred back pain is not a common clinical manifestation of intestinal obstruction. Bile-coloured vomit is associated with higher intestinal obstruction.
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.
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.