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The nurse is irrigating the client's colostomy when the client complains of cramping. What is the most appropriate initial action by the nurse?
- A. Increase the flow of solution
- B. Ask the client to turn to the other side
- C. Pinch the tubing to interrupt the flow of the solution
- D. Remove the tube from the colostomy
Correct Answer: C
Rationale: Pinching the tubing stops the flow, relieving cramping caused by rapid fluid instillation during colostomy irrigation.
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The client diagnosed with AIDS is experiencing voluminous diarrhea. Which interventions should the nurse implement? Select all that apply.
- A. Monitor diarrhea, charting amount, character, and consistency.
- B. Assess the client's tissue turgor every day.
- C. Encourage the client to drink carbonated soft drinks.
- D. Weigh the client daily in the same clothes and at the same time.
- E. Assist the client with a warm sitz bath PRN.
Correct Answer: A,B,D,E
Rationale: Monitoring diarrhea, assessing turgor, daily weighing, and sitz baths address dehydration, skin integrity, and comfort. Carbonated drinks may worsen diarrhea.
The nurse is preparing a client diagnosed with GERD for surgery. Which information warrants notifying the HCP?
- A. The client's Bernstein esophageal test was positive.
- B. The client's abdominal x-ray shows a hiatal hernia.
- C. The client's WBC count is 14,000/mm3.
- D. The client's hemoglobin is 13.8 g/dL.
Correct Answer: C
Rationale: An elevated WBC count (14,000/mm3) suggests infection or inflammation, which could complicate surgery and requires immediate attention. A positive Bernstein test and hiatal hernia are expected in GERD, and a hemoglobin of 13.8 g/dL is within normal limits.
A child with appendicitis is scheduled for surgery this evening. The nurse enters the room and sees the child's mother starting to place hot, wet washcloths on her daughter's abdomen so that 'she will feel better.' The nurse explains that this action is contraindicated because heat:
- A. can cause the appendix to rupture and cause peritonitis.
- B. can mask symptoms of acute appendicitis.
- C. will increase peristalsis throughout the abdomen.
- D. will arrest progression of the disease.
Correct Answer: A
Rationale: Heat can increase inflammation and blood flow, risking appendix rupture and peritonitis in appendicitis.
The nurse is working in an outpatient clinic. Which client is most likely to have a diagnosis of diverticulosis?
- A. A 60-year-old male with a sedentary lifestyle.
- B. A 72-year-old female with multiple childbirths.
- C. A 63-year-old female with hemorrhoids.
- D. A 40-year-old male with a family history of diverticulosis.
Correct Answer: A
Rationale: Diverticulosis is more common in older adults with sedentary lifestyles, which contribute to constipation and increased colonic pressure. Childbirth, hemorrhoids, and family history are less direct risk factors.
The client diagnosed with ulcerative colitis is prescribed a low-residue diet. Which meal selection indicates the client understands the diet teaching?
- A. Grilled hamburger on a wheat bun and fried potatoes.
- B. A chicken salad sandwich and lettuce and tomato salad.
- C. Roast pork, white rice, and plain custard.
- D. Fried fish, whole grain pasta, and fruit salad.
Correct Answer: C
Rationale: A low-residue diet minimizes fiber to reduce bowel irritation, so roast pork, white rice, and plain custard (low-fiber foods) are appropriate. The other options include high-fiber foods like wheat, vegetables, and whole grains, which are contraindicated.