Nokea
The client who has had a hemorrhoidectomy wants to know why she cannot take a sitz bath immediately upon return from the operating room. The nurse's response is based on which of the following concepts?
- A. Heat can stimulate bowel movement too quickly after surgery.
- B. Clients are generally not awake enough for several hours to safely take sitz baths.
- C. Heat applied immediately postoperatively increases the possibility of hemorrhage.
- D. Sitting in water before the sutures are removed may cause infection.
Correct Answer: C
Rationale: Heat increases blood flow, raising the risk of hemorrhage immediately post-hemorrhoidectomy.
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The client with acute diverticulitis has a nasogastric tube draining green liquid bile. Which intervention should the nurse implement?
- A. Document the findings as normal.
- B. Assess the client's bowel sounds.
- C. Determine the client's last bowel movement.
- D. Insert the NG tube at least two (2) more inches.
Correct Answer: A
Rationale: Green bile drainage from an NG tube is normal, indicating proper placement and function, so documenting this is appropriate. Further insertion or other assessments are unnecessary unless other symptoms arise.
The female client came to the clinic complaining of abdominal cramping and at least 10 episodes of diarrhea every day for the last two (2) days. The client just returned from a trip to Mexico. Which intervention should the nurse implement?
- A. Instruct the client to take a cathartic laxative daily.
- B. Encourage the client to drink lots of Gatorade.
- C. Discuss the need to increase protein in the diet.
- D. Explain the client should weigh herself daily.
Correct Answer: B
Rationale: Frequent diarrhea risks dehydration and electrolyte loss; Gatorade replaces fluids and electrolytes. Laxatives worsen diarrhea, protein is secondary, and daily weights are less urgent.
The client diagnosed with IBD is prescribed sulfasalazine (Asulfidine), a sulfonamide antibiotic. Which statement best describes the rationale for administering this medication?
- A. It is administered rectally to help decrease colon inflammation.
- B. This medication slows gastrointestinal (GI) motility and reduces diarrhea.
- C. This medication kills the bacteria causing the exacerbation.
- D. It acts topically on the colon mucosa to decrease inflammation.
Correct Answer: D
Rationale: Sulfasalazine reduces inflammation in IBD by acting topically on the colon mucosa, delivering its active component (mesalamine) to the inflamed areas. It is not primarily an antibiotic, does not slow motility, and is taken orally, not rectally.
The nurse is preparing the postoperative nursing care plan for the client recovering from a hemorrhoidectomy. Which intervention should the nurse implement?
- A. Establish rapport with the client to decrease embarrassment of assessing site.
- B. Encourage the client to lie in the lithotomy position twice a day.
- C. Milk the tube inserted during surgery to allow the passage of flatus
- D. Digitally dilate the rectal sphincter to express old blood.
Correct Answer: A
Rationale: Establishing rapport reduces embarrassment during perianal assessments, promoting comfort post-hemorrhoidectomy. Lithotomy position is not standard for recovery.
A distal pancreatectomy and splenectomy is performed on a client with cancer of the pancreas. He is returned to his room postoperatively. The client is sleepy but can answer simple questions appropriately. His dressing is dry and intact. Vital signs are within normal limits. Which of the following nursing measures must be done before the nurse leaves the room?
- A. Inform his wife that he has returned to his room.
- B. Check to see if the indwelling urinary catheter bag is correctly attached to the bed frame.
- C. Assess to be sure he is not experiencing any discomfort.
- D. Put all four side rails in the high position.
Correct Answer: D
Rationale: Raising all four side rails ensures safety for a sleepy postoperative client, preventing falls.