Nokea
The 70-year-old client is admitted to the medical unit diagnosed with acute diverticulitis. Which interventions should the nurse implement? Select all that apply.
- A. Tell the client not to eat or drink.
- B. Start an intravenous line.
- C. Assess the client for abdominal tenderness.
- D. Have the dietitian consult for a low-residue diet.
- E. Place the client on bedrest with bathroom privileges.
Correct Answer: A,B,C,E
Rationale: NPO status, IV line, abdominal assessment, and bedrest manage acute diverticulitis by resting the bowel and monitoring complications. Low-residue diets are for stable phases.
You may also like to solve these questions
The charge nurse is monitoring client laboratory values. Which value is expected in the client with cholecystitis who has chronic inflammation?
- A. An elevated white blood cell (WBC) count.
- B. A decreased lactate dehydrogenase (LDH).
- C. An elevated alkaline phosphatase.
- D. A decreased direct bilirubin level.
Correct Answer: C
Rationale: Chronic cholecystitis often causes elevated alkaline phosphatase due to bile duct irritation or obstruction. WBC elevation is more acute, and bilirubin or LDH changes are less specific.
The client recovering from acute pancreatitis who has been NPO asks the nurse, “When can I start eating again?” Which response by the nurse is most accurate?
- A. “As soon as you start to feel hungry you can begin eating.”
- B. “When I hear that your bowel sounds are active and you are passing flatus.”
- C. “When your pain is controlled and your serum lipase level has decreased.”
- D. “You will be NPO for at least more 2 weeks; oral intake stimulates the pancreas.”
Correct Answer: C
Rationale: A. Regaining appetite is a positive sign, but it must be accompanied by a decrease in pain before the client is allowed to take food orally. B. Intestinal peristalsis may be slowed due to inflammation associated with acute pancreatitis, but the return of bowel sounds and flatus is not used to determine when to begin oral intake. C. This response is correct. Once pain is controlled and the serum enzyme levels begin to decrease, the client can begin oral intake. These are signs that the pancreas is healing. D. There is no specific time limit for being NPO.
Which task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)?
- A. Evaluate the client’s intake and output.
- B. Take the client’s vital signs.
- C. Change the client’s intravenous solution.
- D. Assess the client’s perianal area.
Correct Answer: B
Rationale: Taking vital signs is within the UAP’s scope and supports monitoring in gastroenteritis. Evaluating intake/output, changing IV solutions, and assessing skin require RN skills.
The client has been experiencing difficulty and straining when expelling feces. Which intervention should the nurse discuss with the client?
- A. Explain some blood in the stool will be normal for the client.
- B. Instruct the client in manual removal of feces.
- C. Encourage the client to use a cathartic laxative on a daily basis.
- D. Place the client on a high-fiber diet.
Correct Answer: D
Rationale: A high-fiber diet promotes regular, softer stools, reducing straining. Blood is not normal, manual removal is invasive, and daily laxatives cause dependency.
Which gastrointestinal assessment data should the nurse expect to find when assessing the client in end-stage liver failure?
- A. Hypoalbuminemia and muscle wasting.
- B. Oligomenorrhea and decreased body hair.
- C. Clay-colored stools and hemorrhoids.
- D. Dyspnea and caput medusae.
Correct Answer: A
Rationale: Hypoalbuminemia and muscle wasting are common in end-stage liver failure due to impaired protein synthesis and malnutrition. Other options include less specific or unrelated findings.