Nokea
The nurse is conducting a telephone call following up with a client with a colostomy placed two weeks ago. Select the findings reported by the client that require follow-up by the nurse.
- A. The client reports that he has no pain at the stoma.
- B. He states that the stoma is red and moist.
- C. He reports changing the appliance daily
- D. He reports using moisturizing soap around the stoma.
- E. The client notes that he empties the pouch when it is one-half to one-third full of stool.
- F. The client stated that his stoma has been getting smaller in size since surgery.
Correct Answer: C,D
Rationale: Changing the appliance daily (C) may indicate improper fit or skin irritation, requiring assessment. Using moisturizing soap (D) can interfere with appliance adhesion and cause skin issues, necessitating education on proper skin care.
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The nurse is caring for a client receiving total parenteral nutrition (TPN), which was initiated twelve hours ago. The priority assessment for this client is which of the following?
- A. Urine output
- B. Oral temperature
- C. Weight
- D. Capillary blood glucose
Correct Answer: D
Rationale: TPN contains high concentrations of glucose, which can lead to hyperglycemia, especially in the early stages of administration. Monitoring capillary blood glucose is critical to detect and manage this potential complication.
The nurse is teaching a client about peptic ulcer disease. Which of the following statements should the nurse include?
- A. You should take aspirin if you have mild aches or pains.
- B. You will need to consume liquids one hour after each meal.
- C. It will be important to reduce the stress in your life.
- D. Take your prescribed omeprazole with food.
Correct Answer: C
Rationale: Stress reduction (C) helps manage peptic ulcer disease by reducing acid secretion. Aspirin (A) worsens ulcers, liquids with meals (B) are not restricted, and omeprazole (D) is taken before meals.
A client with peptic ulcer disease from chronic nonsteroidal anti-inflammatory drug (NSAID) use is prescribed misoprostol. The nurse would be correct in informing the client that this medication does which of the following?
- A. Decreases gas formation
- B. Increases the speed of gastric emptying
- C. Lines the stomach for protection
- D. Increases the lower esophageal sphincter pressure
Correct Answer: C
Rationale: Misoprostol (C) protects the stomach by increasing mucus production and reducing acid secretion, helping to heal NSAID-induced ulcers.
A nurse is caring for a client diagnosed with a duodenal ulcer. Which medication facilitates healing by forming a protective lining over the client's ulcer?
- A. Famotidine
- B. Omeprazole
- C. Sucralfate
- D. Cimetidine
Correct Answer: C
Rationale: Sucralfate (C) forms a protective barrier over the ulcer, promoting healing by shielding it from stomach acid. Famotidine (A) and cimetidine (D) are H2 blockers, and omeprazole (B) is a proton pump inhibitor, which reduce acid but do not form a physical barrier.
A nurse is caring for a client with ulcerative colitis who has experienced severe diarrhea for the past 24 hours. When assessing the client, the nurse should watch for signs of which of the following?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Malnutrition
- D. Malabsorption
Correct Answer: C
Rationale: Severe diarrhea in ulcerative colitis leads to nutrient loss, increasing the risk of malnutrition (C). Acid-base imbalances (A, B) and malabsorption (D) are possible but less immediate concerns.