Nokea
The nurse is planning the care of a client who has had an abdominal-perineal resection for cancer of the colon. Which interventions should the nurse implement?
- A. Provide meticulous skin care to stoma.
- B. Assess the flank incision.
- C. Maintain the indwelling catheter.
- D. Irrigate the (JP) drains every shift.
- E. Position the client semirecumbent.
Correct Answer: A,C,E
Rationale: Stoma skin care prevents irritation, an indwelling catheter is maintained post-surgery to monitor output, and a semirecumbent position aids breathing and comfort. Flank incisions are not typical, and JP drains are not irrigated.
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The client with a history of a duodenal ulcer is hospitalized with upper abdominal discomfort and projectile vomiting that has a foul odor. The nurse immediately notifies the HCP, concluding that the client may have developed which complication?
- A. Gastric perforation
- B. Gastrointestinal hemorrhage
- C. Gastric outlet obstruction
- D. Helicobacter pylori infection
Correct Answer: C
Rationale: A. Symptoms of perforation include severe abdominal pain; vomiting usually does not occur. B. The client with GI hemorrhage would have bright red or coffee-ground-colored emesis. C. Symptoms of gastric outlet obstruction include abdominal pain and projectile vomiting when the stomach fills enough to stimulate afferent nerve fibers relaying information to the vomiting center in the brain. The emesis may have a foul odor or contain food particles if the contents have been dormant in the stomach for a prolonged time period. D. Infection with H. pylori is not a complication of PUD; rather, it is a major cause of peptic ulcers.
The client is prescribed infliximab 5 mg/kg every 8 weeks for treatment of Crohn’s disease. The client weighs 116 lb. How many milligrams (mg) should the nurse administer? _________ mg (Record your answer rounded to a whole number.)
Correct Answer: 264
Rationale: To calculate the dose: 1. Convert weight to kilograms: 116 lb ÷ 2.2 = 52.727 kg. 2. Calculate dose: 5 mg/kg × 52.727 kg = 263.635 mg. 3. Round to a whole number: 264 mg.
The nurse is assessing a client complaining of abdominal pain. Which data support the diagnosis of a bowel obstruction?
- A. Steady, aching pain in one specific area.
- B. Sharp back pain radiating to the flank.
- C. Sharp pain increases with deep breaths.
- D. Intermittent colicky pain near the umbilicus.
Correct Answer: D
Rationale: Intermittent colicky pain near the umbilicus is characteristic of bowel obstruction due to peristalsis against the blockage. Steady pain, back pain, and pain with breathing suggest other conditions.
The client diagnosed with Crohn's disease is crying and tells the nurse, 'I can't take it anymore. I never know when I will get sick and end up here in the hospital.' Which statement is the nurse's best response?
- A. I understand how frustrating this must be for you.
- B. You must keep thinking about the good things in your life.
- C. I can see you are very upset. I'll sit down and we can talk.
- D. Are you thinking about doing anything like committing suicide?
Correct Answer: C
Rationale: Acknowledging the client's distress and offering to talk provides emotional support and opens communication to address concerns. The other responses are less therapeutic, either minimizing the issue or jumping to assumptions about suicide risk.
A 32-year-old female is admitted for a hemorrhoidectomy. During the nursing assessment, all of the following factors are elicited. Which one is most likely to have contributed to the development of hemorrhoids?
- A. The client states that she usually cleans herself from back to front after a bowel movement.
- B. The client says her mother and grandmother had hemorrhoids.
- C. The client has had four pregnancies.
- D. The client eats bran every day.
Correct Answer: C
Rationale: Multiple pregnancies increase intra-abdominal pressure, a major risk factor for hemorrhoids. Family history may contribute, but pregnancies are more directly linked.