Nokea
The client who has had an abdominal perineal resection is being discharged. Which discharge information should the nurse teach?
- A. The stoma should be a white, blue, or purple color.
- B. Limit ambulation to prevent the pouch from coming off.
- C. Take pain medication when the pain level is at an '8.'
- D. Empty the pouch when it is one-third to one-half full.
Correct Answer: D
Rationale: Emptying the pouch when one-third to one-half full prevents leaks and skin irritation. A healthy stoma is pink/moist, ambulation is encouraged, and pain medication should be taken before pain becomes severe.
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The nurse is completing a home visit with the client who had a partial resection of the ileum for Crohn’s disease 4 weeks previously. The nurse should collect additional information when the client makes which statement?
- A. “My stools float and seem to have fat in them.”
- B. “I have gained 5 pounds since I left the hospital.”
- C. “I am still avoiding milk and milk products.”
- D. “I am having only two formed stools per day.”
Correct Answer: A
Rationale: A. The nurse should collect additional information when the client states having stools that float and have fat in them. Bile salts are absorbed in the terminal ileum. Disease in this area or resection of the ileum can result in poor fat absorption and loss of fat in the stool. The presence of bile salts leads to diarrhea. B. Weight gain is a positive sign after small bowel resection for Crohn’s disease. C. Many clients with Crohn’s disease develop lactose intolerance and therefore should avoid milk products. D. Formed stools are a positive sign after small bowel resection for Crohn’s disease.
The client who has had an appendectomy and has a Penrose drain in place has recovered from anesthesia. The nurse places her in a semi-sitting position. What is the primary reason for selecting this position?
- A. To promote optimal ventilation
- B. To promote drainage from the abdominal cavity
- C. To prevent pressure sores from developing
- D. To reduce tension on the suture line
Correct Answer: B
Rationale: The semi-sitting position promotes gravity-dependent drainage through the Penrose drain from the abdominal cavity.
The nurse is caring for the client diagnosed with hemorrhoids. Which statement indicates further teaching is needed?
- A. I should increase fruits, bran, and fluids in my diet.
- B. I will use warm compresses and take sitz baths daily.
- C. I must take a laxative every night and have a stool daily.
- D. I can use an analgesic ointment or suppository for pain.
Correct Answer: C
Rationale: Daily laxatives are not necessary and may cause dependency; hemorrhoid management focuses on diet and symptom relief. Increased fiber/fluids, sitz baths, and analgesics are correct.
The 40-year-old client is recovering from an exacerbation of chronic pancreatitis. As the client prepares for discharge, the client makes several statements to the nurse. Which statement should be concerning because it could inhibit the client’s ability to accomplish the developmental tasks of middle adulthood?
- A. “I’m planning on continuing to be active in the local town service club.”
- B. “I enjoy my job; I should be able to return to work in about 3 to 4 weeks.”
- C. “I’ve missed friends and look forward to having a glass of wine with them.”
- D. “My spouse has been very supportive during my lengthy hospitalization.”
Correct Answer: C
Rationale: A. Volunteer activities meet the developmental task of middle adulthood of generativity. B. Planning to return to work meets the developmental task of middle adulthood of generativity. C. Consuming alcohol will cause continued progression of the pancreatic disease and could eventually result in the inability to work or to participate in community service. This statement should be concerning to the nurse. D. This statement indicates that the client has the support of another.
The nurse writes the problem 'risk for impaired skin integrity' for a client with a sigmoid colostomy. Which expected outcome would be appropriate for this client?
- A. The client will have intact skin around the stoma.
- B. The client will be able to change the ostomy bag.
- C. The client will express anxiety about the body changes.
- D. The client will maintain fluid balance.
Correct Answer: A
Rationale: Intact skin around the stoma directly addresses the risk for impaired skin integrity due to colostomy leakage or irritation. Other outcomes are unrelated or secondary.