Nokea
The nurse is caring for a client with an exacerbation of ulcerative colitis. Which of the following nursing measures should be included in the client's plan of care?
- A. Encourage regular use of antidiarrheal medications.
- B. Incorporate frequent rest periods into the client's schedule.
- C. Have the client maintain a high-fiber diet.
- D. Wear a gown when providing direct client care.
Correct Answer: B
Rationale: The correct answer is B: Incorporate frequent rest periods into the client's schedule. Rest periods are essential for managing ulcerative colitis exacerbations as they help reduce stress on the digestive system. Antidiarrheal medications (A) may worsen the condition by masking symptoms and delaying appropriate treatment. High-fiber diets (C) can aggravate symptoms in some individuals with ulcerative colitis. Wearing a gown (D) is unrelated to managing ulcerative colitis exacerbations.
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A client is scheduled for an abdominal perineal resection with permanent colostomy. Which of the following measures would most likely be included in the plan for the client's preoperative preparation?
- A. Keep the client NPO for 2 days before surgery.
- B. Administer kanamycin (Kantrex) the night before surgery.
- C. Inform the client that chest tubes will be in place after surgery.
- D. Advise the client to limit activity.
Correct Answer: B
Rationale: The correct answer is B: Administer kanamycin (Kantrex) the night before surgery. This antibiotic is typically given preoperatively to reduce the risk of infection during the surgical procedure. It helps to eliminate or reduce the number of bacteria in the gastrointestinal tract, which could potentially contaminate the surgical site during the abdominal perineal resection with permanent colostomy.
A: Keeping the client NPO for 2 days before surgery is not necessary for this procedure and could lead to unnecessary dehydration and discomfort.
C: Informing the client that chest tubes will be in place after surgery is not directly related to preoperative preparation for this specific surgery.
D: Advising the client to limit activity is important for postoperative recovery, but it is not a preoperative measure specific to this surgery.
A client has a nasogastric tube inserted at the time of abdominal perineal resection with permanent colostomy. This tube will most likely be removed when the client demonstrates:
- A. Absence of nausea and vomiting.
- B. Passage of mucus from the rectum.
- C. Passage of flatus and feces from the colostomy.
- D. Absence of stomach drainage for 24 hours.
Correct Answer: C
Rationale: The correct answer is C: Passage of flatus and feces from the colostomy. This indicates that the gastrointestinal tract is functioning properly post-operatively. The nasogastric tube is typically removed once the client's bowel function has returned, as evidenced by the passage of flatus and feces from the colostomy. This indicates that the client's bowels are working and there is no longer a need for the tube to decompress the stomach. Choices A, B, and D are incorrect because the absence of nausea and vomiting, passage of mucus from the rectum, and absence of stomach drainage do not directly indicate the return of normal bowel function, which is the key factor for removing the nasogastric tube in this scenario.
Which of the following techniques would the nurse use first to determine if a nasogastric tube is positioned in the stomach?
- A. Aspirating with a syringe and observing for the return of gastric contents.
- B. Irrigating with normal saline and observing for the return of solution.
- C. Placing the tube's free end in water and observing for air bubbles.
- D. Instilling air and auscultating over the epigastric area for the presence of the tube.
Correct Answer: A
Rationale: The correct answer is A: Aspirating with a syringe and observing for the return of gastric contents. This technique is used first because it directly confirms the tube's placement by withdrawing gastric contents. If the tube is in the stomach, gastric contents will be aspirated.
Choice B is incorrect because irrigating with normal saline does not confirm the tube placement in the stomach. Choice C is incorrect because placing the tube's free end in water and observing for air bubbles is not an accurate method to confirm stomach placement. Choice D is incorrect because instilling air and auscultating over the epigastric area may not provide definitive confirmation of tube placement in the stomach.
When assessing the client with celiac disease, the nurse can expect to find which of the following?
- A. Steatorrhea
- B. Jaundiced sclerae
- C. Clay-colored stools
- D. Widened pulse pressure
Correct Answer: A
Rationale: The correct answer is A: Steatorrhea. In celiac disease, the small intestine is unable to absorb nutrients properly due to gluten intolerance, leading to fat malabsorption. Steatorrhea is a common symptom characterized by foul-smelling, greasy, and bulky stools. Jaundiced sclerae (B) are associated with liver dysfunction, not celiac disease. Clay-colored stools (C) may indicate issues with the liver or bile ducts, not celiac disease. Widened pulse pressure (D) is not typically a direct symptom of celiac disease but may be seen in conditions like aortic regurgitation.
A client with viral hepatitis states, 'I am so yellow.' The nurse most appropriately would
- A. Assist the client in expressing feelings.
- B. Do most of the activities of daily living for the client.
- C. Provide information to the client only when the client requests it.
- D. Restrict visitors until the jaundice subsides.
Correct Answer: A
Rationale: The correct answer is A because assisting the client in expressing feelings shows empathy and addresses the client's emotional needs. It helps the client cope with the physical manifestations of the illness. Choice B is incorrect as it promotes dependence. Choice C is incorrect because providing information only upon request may not address the client's emotional distress. Choice D is incorrect as restricting visitors may further isolate the client.