Nokea
The client diagnosed with acute diverticulitis is complaining of severe abdominal pain. On assessment, the nurse finds a hard, rigid abdomen and T 102°F. Which intervention should the nurse implement?
- A. Notify the health-care provider.
- B. Prepare to administer a Fleet's enema.
- C. Administer an antipyretic suppository.
- D. Continue to monitor the client closely.
Correct Answer: A
Rationale: A rigid abdomen and fever (102°F) suggest possible perforation or peritonitis, requiring immediate HCP notification for evaluation and possible surgical intervention. Enemas are contraindicated, and antipyretics or monitoring delay critical action.
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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.
The client is prescribed infliximab 5 mg/kg every 8 weeks for treatment of Crohn’s disease. The client weighs 116 lb. How many milligrams (mg) should the nurse administer? _________ mg (Record your answer rounded to a whole number.)
Correct Answer: 264
Rationale: To calculate the dose: 1. Convert weight to kilograms: 116 lb ÷ 2.2 = 52.727 kg. 2. Calculate dose: 5 mg/kg × 52.727 kg = 263.635 mg. 3. Round to a whole number: 264 mg.
The nurse is caring for the client with Clostridium difficile. Which intervention should the nurse implement to prevent health-care associated infection (HAl) spread to other clients?
- A. Wash hands with Betadine for two (2) minutes after giving care.
- B. Wear nonsterile gloves when handling GI excretions.
- C. Clean the perianal area with soap and water after each stool.
- D. Flush the commode twice when disposing of stool.
Correct Answer: C
Rationale: Cleaning the perianal area with soap and water after each stool reduces the risk of Clostridium difficile spore transmission, which is critical for preventing healthcare-associated infections. Betadine is not standard, gloves are insufficient alone, and flushing twice is not evidence-based.
The client who had an abdominal surgery has a Jackson Pratt (JP) drainage tube. Which assessment data warrant immediate intervention by the nurse?
- A. The bulb is round and has 40 mL of fluid.
- B. The drainage tube is taped to the dressing.
- C. The JP insertion site is pink and has no drainage.
- D. The JP bulb has suction and is sunken in.
Correct Answer: A
Rationale: A round JP bulb with 40 mL of fluid indicates loss of suction, risking fluid accumulation and infection, requiring immediate intervention. Taping, pink site, and suction are normal.
The client is 6 days post—total proctocolectomy with ileostomy creation for ulcerative colitis. The client’s ileostomy is draining large amounts of liquid stool, and the client has dizziness with ambulation. Which parameters should the nurse assess immediately?
- A. Pulse rate for the last 24 hours
- B. Urine output for the last 24 hours
- C. Weight over the last 3 days
- D. Ability to move the lower extremities
- E. Temperature readings for the last 24 hours
Correct Answer: A, B, C, E
Rationale: The nurse should assess for increasing pulse rate over time because it is a sign of dehydration; large amounts of ileostomy output can result in dehydration, and the dizziness with ambulation could be from dehydration. B. The nurse should assess for decreasing urine output because it is a sign of dehydration; large amounts of ileostomy output can result in dehydration, and the dizziness with ambulation could be from dehydration. C. The nurse should assess for decreasing weight because it is a sign of dehydration; large amounts of ileostomy output can result in dehydration, and the dizziness with ambulation could be from dehydration. D. The ability to move the lower extremities is not related to dehydration. E. The nurse should assess the temperature readings because a low-grade temperature is a sign of dehydration; large amounts of ileostomy output can result in dehydration, and the dizziness with ambulation could be from dehydration.