Nokea
The nurse is admitting a patient with an exacerbation of inflammatory bowel disease (IBD). Which of the following nursing actions should the nurse include in the plan of care?
- A. Restrict oral fluid intake.
- B. Monitor stools for blood.
- C. Increase dietary fibre intake.
- D. Ambulate four times daily.
Correct Answer: B
Rationale: Since anemia or hemorrhage may occur with IBD, stools should be assessed for the presence of blood. The other actions would not be appropriate for the patient with IBD. Because dietary fibre may increase gastrointestinal (GI) motility and exacerbate the diarrhea, severe fatigue is common with IBD exacerbations, and dehydration may occur.
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The nurse is teaching a patient who has persistent constipation, about the use of psyllium. Which of the following information should the nurse include?
- A. Absorption of fat-soluble vitamins may be reduced by fibre-containing laxatives.
- B. Dietary sources of fibre should be eliminated to prevent excessive gas formation.
- C. Use of this type of laxative to prevent constipation does not cause adverse effects.
- D. Large amounts of fluid should be taken to prevent impaction or bowel obstruction.
Correct Answer: D
Rationale: A high fluid intake is needed when patients are using bulk-forming laxatives to avoid worsening constipation. Although bulk-forming laxatives are generally safe, the nurse should emphasize the possibility of constipation or obstipation if inadequate fluid intake occurs. Although increased gas formation is likely to occur with increased dietary fibre, the patient should gradually increase dietary fibre and eventually may not need the psyllium. Fat-soluble vitamin absorption is blocked by stool softeners and lubricants, not by bulk-forming laxatives.
The nurse is conducting preoperative preparation for a patient scheduled for an abdominal-perineal resection. Which of the following actions should the nurse implement?
- A. Give IV antibiotics starting 24 hours before surgery to reduce the number of bowel bacteria.
- B. Teach the patient that activities such as sitting at the bedside will be started the first postoperative day.
- C. Instruct the patient that another surgery in 8-12 weeks will be used to create an ileal-anal reservoir.
- D. Administer polyethylene glycol lavage solution (GOLYTELY) to ensure that the bowel is empty before the surgery.
Correct Answer: D
Rationale: A bowel-cleansing agent is used to empty the bowel before surgery to reduce the risk for infection. Oral antibiotics (rather than IV antibiotics) are given to reduce colonic and rectal bacteria. Sitting is contraindicated after an abdominal-perineal resection. A permanent colostomy is created with this surgery.
The nurse is admitting a patient for evaluation of right lower quadrant abdominal pain accompanied by nausea and vomiting. On assessment the temperature is 37.5°C (99.5°F), heart rate 105, respiratory rate 20 and an O2 saturation of 90%. Which of the following actions should the nurse take?
- A. Check for rebound tenderness.
- B. Assist the patient to cough and deep breathe.
- C. Administer oxygen via nasal cannula.
- D. Encourage the patient to take sips of clear liquids.
Correct Answer: C
Rationale: The patient's clinical manifestations are consistent with appendicitis but the main priority is to administer oxygen as the O2 saturation is only 90%. The patient should be NPO in case immediate surgery is needed. Checking for rebound tenderness frequently is unnecessary and uncomfortable for the patient. The patient will need to know how to cough and deep breathe postoperatively, but coughing will increase pain at this time.
Which of the following actions should the nurse implement when initiating the initial plan of care for a patient admitted with acute diverticulitis?
- A. Give stool softeners.
- B. Administer IV fluids.
- C. Order a diet high in fibre and fluids.
- D. Prepare the patient for colonoscopy.
Correct Answer: B
Rationale: A patient with acute diverticulitis will be NPO and given parenteral fluids. A diet high in fibre and fluids will be implemented before discharge. Bulk-forming laxatives, rather than stool
The nurse is caring for a patient with Crohn's disease who develops a fever and symptoms of a urinary tract infection (UTI) with tan, fecal-smelling urine. Which of the following information should the nurse teach the patient?
- A. To clean the perianal area carefully after any stools
- B. About fistula formation between the bowel and bladder
- C. To empty the bladder before and after sexual intercourse
- D. About the effects of corticosteroid use on immune function
Correct Answer: B
Rationale: Fistulas between the bowel and bladder occur in Crohn's disease and can lead to UTI. There is no information indicating that the patient's risk for UTI is caused by poor cleaning or not voiding before and after intercourse. Steroid use may increase the risk for infection, but the characteristics of the patient's urine indicate that a fistula has occurred.