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The nurse is caring for a patient who has a large bowel obstruction that occurred as a result of diverticulosis. Which of the following symptoms should the nurse monitor for when assessing the patient?
- A. Referred back pain
- B. Metabolic alkalosis
- C. Projectile vomiting
- D. Abdominal distension
Correct Answer: D
Rationale: Abdominal distension is seen in lower intestinal obstruction. Metabolic alkalosis is common in high intestinal obstruction because of the loss of HCl acid from vomiting. Referred back pain is not a common clinical manifestation of intestinal obstruction. Bile-coloured vomit is associated with higher intestinal obstruction.
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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.
The nurse is providing teaching to a patient with a new ileostomy. Which of the following daily drainage amounts should the nurse inform the patient is expected after the bowel adjusts to the ileostomy?
- A. 400 mL
- B. 600 mL
- C. 800 mL
- D. 1000 mL
Correct Answer: C
Rationale: After the proximal small bowel adapts to reabsorb more fluid, the average amount of ileostomy drainage is about 800 mL daily.
The nurse is caring for a patient who is incontinent of watery diarrhea and has been diagnosed with Clostridium difficile. Which of the following actions should the nurse include in the plan of care?
- A. Order a diet with no dairy products for the patient.
- B. Place the patient in a private room with contact isolation.
- C. Teach the patient about why antibiotics are not being used.
- D. Educate the patient about proper food handling and storage.
Correct Answer: B
Rationale: Because C. difficile is highly contagious, the patient should be placed in a private room and contact precautions should be used. There is no need to restrict dairy products for this type of diarrhea. Metronidazole is frequently used to treat C. difficile. Improper food handling and storage do not cause C. difficile.
The nurse is providing discharge teaching for a patient with a new colostomy. Which of the following patient actions indicates that the teaching has been effective?
- A. Empties the colostomy bag once it is one-third full.
- B. Drinks at least 1000 mL of fluid a day.
- C. Contacts the health care provider if there is pain or erythema in the peristomal area.
- D. Takes acetaminophen when a temperature of 38.3°C is present.
Correct Answer: C
Rationale: The health care provider should be contacted if there is pain or erythema in the peristomal area. If the patient has a temperature, the health care provider should be contacted. The colostomy should be emptied before it becomes one-third full. The patient should drink at least 1500-2000 mL per day to avoid dehydration.
The nurse is caring for a patient with an acute exacerbation of ulcerative colitis having 14-16 bloody stools a day and crampy abdominal pain associated with the diarrhea. Which of the following actions should the nurse take?
- A. Place the patient on NPO status.
- B. Administer IV metoclopramide.
- C. Teach the patient about total colectomy surgery.
- D. Administer cobalamin injections.
Correct Answer: A
Rationale: An initial therapy for an acute exacerbation of inflammatory bowel disease (IBD) is to rest the bowel by making the patient NPO. Cobalamin (vitamin B12) is absorbed in the ileum, which is not affected by ulcerative colitis. Although total colectomy is needed for some patients, there is no indication that this patient is a candidate. Metoclopramide increases peristalsis and will worsen symptoms.