Nokea
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.
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The nurse is caring for a patient who has a new diagnosis of Crohn's disease after having frequent diarrhea and a weight loss of 4.5 kg over 2 months. Which of the following topics should the nurse plan to include in the teaching plan?
- A. Medication use
- B. Fluid restriction
- C. Enteral nutrition
- D. Activity restrictions
Correct Answer: A
Rationale: Medications are used to induce and maintain remission in patients with inflammatory bowel disease (IBD). Decreased activity level is indicated only if the patient has severe fatigue and weakness. Fluids are needed to prevent dehydration. There is no advantage to enteral feedings.
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.
Which of the following nursing actions is most important to include in the plan of care for a patient who had an abdominal-perineal resection the previous day?
- A. Teach about a low-residue diet.
- B. Monitor output from the stoma.
- C. Assess the perineal drainage and incision.
- D. Encourage acceptance of the colostomy stoma.
Correct Answer: C
Rationale: Because the perineal wound is at high risk for infection, the initial care is focused on assessment and care of this wound. Teaching about diet is best done closer to discharge from the hospital. There will be very little drainage into the colostomy until peristalsis returns. The patient will be encouraged to assist with the colostomy, but this is not the highest priority in the immediate postoperative period.
Before undergoing a colon resection for cancer of the colon, a patient has an elevated carcinoembryonic antigen (CEA) test. Which of the following explanations should the nurse provide to the patient about this test?
- A. It confirms the diagnosis of colon cancer.
- B. It monitors the tumour status after surgery.
- C. It identifies the extent of cancer spread or metastasis.
- D. It determines the need for postoperative chemotherapy.
Correct Answer: B
Rationale: CEA is used to monitor for cancer recurrence after surgery. CEA levels do not help determine whether there is metastasis of the cancer. Confirmation of the diagnosis is made on the basis of biopsy. Chemotherapy use is based on factors other than CEA.
A patient tells the nurse, 'I have problems with constipation now that I am older, so I use a suppository every morning.' Which of the following actions should the nurse take first?
- A. Encourage the patient to increase oral fluid intake
- B. Inform the patient that a daily bowel movement is unnecessary.
- C. Assess the patient about individual risk factors for constipation.
- D. Suggest that the patient increase dietary intake of high-fibre foods.
Correct Answer: C
Rationale: The nurse's initial action should be further assessment of the patient for risk factors for constipation and for usual bowel pattern. The other actions may be appropriate but will be based on the assessment.