Nokea
The client is scheduled for an abdominal-perineal resection for cancer of the rectum. Which components should the nurse include in the client’s preoperative education? Select all that apply.
- A. The enterostomal nurse will be visiting the client prior to surgery.
- B. After surgery rectal suppositories will be given to prevent straining and stress.
- C. The bowel will be cleansed before surgery with a laxative, enema, or whole-gut lavage.
- D. Oral or intravenous (IV) antibiotics will be prescribed to be given preoperatively.
- E. A member of the surgical team will discuss the risk of postoperative sexual dysfunction.
Correct Answer: A,C,D,E
Rationale: An abdominal-perineal resection removes the sigmoid colon, rectum, and anus. As a result the client will have a permanent colostomy. The enterostomal nurse will identify and mark an appropriate stoma location after considering the client’s skinfolds, clothing preferences, and the level of the colostomy. The bowel is cleansed preoperatively to reduce the risk of peritoneal contamination by bowel contents during surgery. Antibiotics are prescribed to be given preoperatively to reduce the risk of peritoneal contamination by bowel contents during surgery. Postoperatively the client with an abdominal-perineal resection is at risk for sexual dysfunction and urinary incontinence as a result of nerve damage. This needs to be discussed with the client prior to surgery by the surgeon or a member of the surgical team.
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The client is hospitalized with a large bowel obstruction resulting in massive abdominal distention. Which assessment findings should be most concerning to the nurse?
- A. Urine specific gravity value of 1.020
- B. High-pitched and tinkling bowel sounds
- C. Decreased lung sounds in both lung bases
- D. Client describes abdominal pain as colicky
Correct Answer: C
Rationale: Decreased lung sounds are the most concerning finding because it can be life-threatening. Massive distention can impair function of the diaphragm, which in turn leads to atelectasis and compromised respiratory function.
Which statement indicates to the emergency department nurse the client diagnosed with acute gastroenteritis understands the discharge teaching?
- A. I will probably have some leg cramps while I have gastroenteritis.
- B. I should decrease my fluid intake until the diarrhea subsides.
- C. I should reintroduce solid foods very slowly back into my diet.
- D. I should only drink bottled water until the abdominal cramping stops.
Correct Answer: C
Rationale: Slowly reintroducing solid foods prevents GI irritation, indicating understanding of gastroenteritis recovery. Leg cramps are possible but not emphasized, and decreasing fluids or bottled water is incorrect.
The postanesthesia care nurse is caring for a client who had abdominal surgery and is complaining of nausea. Which intervention should the nurse implement first?
- A. Medicate the client with a narcotic analgesic (IVP).
- B. Assess the nasogastric tube for patency.
- C. Check the temperature for elevation.
- D. Hyperextend the neck to prevent stridor.
Correct Answer: B
Rationale: Assessing NG tube patency ensures it is functioning to prevent nausea from gastric distension. Narcotics may worsen nausea, fever is secondary, and neck hyperextension is irrelevant.
The nurse is caring for clients in an outpatient clinic. Which information should the nurse teach regarding the American Cancer Society's recommendations for the early detection of colon cancer?
- A. Beginning at age 60, a digital rectal examination should be done yearly.
- B. After reaching middle age, a yearly fecal occult blood test should be done.
- C. Have a colonoscopy at age 50 and then once every five (5) to 10 years.
- D. A flexible sigmoidoscopy should be done yearly after age 40.
Correct Answer: C
Rationale: The American Cancer Society recommends a colonoscopy starting at age 45–50, then every 5–10 years for average-risk individuals, as it effectively detects polyps and cancer. Other options are outdated or incorrect.
The client diagnosed with ulcerative colitis has an ileostomy. Which statement indicates the client needs more teaching concerning the ileostomy?
- A. My stoma should be pink and moist.
- B. I will irrigate my ileostomy every morning.
- C. If I get a red, bumpy, itchy rash I will call my HCP.
- D. I will change my pouch if it starts leaking.
Correct Answer: B
Rationale: Ileostomies typically do not require routine irrigation, as the output is liquid and continuous, unlike colostomies. The other statements reflect correct understanding of stoma care and management.