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Which data should the nurse expect to assess in the client who had an upper gastrointestinal (UGI) series?
- A. Chalky white stools.
- B. Increased heart rate.
- C. A firm, hard abdomen.
- D. Hyperactive bowel sounds.
Correct Answer: A
Rationale: A UGI series uses barium, which can cause chalky white stools as it is excreted. Heart rate, abdominal firmness, and bowel sounds are not typically affected.
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The nurse is caring for clients in an outpatient clinic. Which information should the nurse teach regarding the American Cancer Society's recommendations for the early detection of colon cancer?
- A. Beginning at age 60, a digital rectal examination should be done yearly.
- B. After reaching middle age, a yearly fecal occult blood test should be done.
- C. Have a colonoscopy at age 50 and then once every five (5) to 10 years.
- D. A flexible sigmoidoscopy should be done yearly after age 40.
Correct Answer: C
Rationale: The American Cancer Society recommends a colonoscopy starting at age 45–50, then every 5–10 years for average-risk individuals, as it effectively detects polyps and cancer. Other options are outdated or incorrect.
The nurse is caring for the client scheduled for an abdominal perineal resection for Stage IV colon cancer. Which client problem should the nurse include in the intraoperative care plan?
- A. Fluid volume deficit.
- B. Impaired tissue perfusion.
- C. Infection of surgical site.
- D. Risk for immunosuppression.
Correct Answer: A
Rationale: Fluid volume deficit is a key intraoperative concern due to blood loss and fluid shifts during abdominal perineal resection. Perfusion, infection, and immunosuppression are postoperative risks.
The nurse writes the problem 'risk for impaired skin integrity' for a client with a sigmoid colostomy. Which expected outcome would be appropriate for this client?
- A. The client will have intact skin around the stoma.
- B. The client will be able to change the ostomy bag.
- C. The client will express anxiety about the body changes.
- D. The client will maintain fluid balance.
Correct Answer: A
Rationale: Intact skin around the stoma directly addresses the risk for impaired skin integrity due to colostomy leakage or irritation. Other outcomes are unrelated or secondary.
The 36-year-old female client diagnosed with anorexia nervosa tells the nurse 'I am so fat. I won't be able to eat today.' Which response by the nurse is most appropriate?
- A. Can you tell me why you think you are fat?
- B. You are skinny. Many women wish they had your problem.
- C. If you don't eat, we will have to restrain you and feed you.
- D. Not eating might cause physical problems.
Correct Answer: A
Rationale: Asking why the client feels fat explores distorted body image, a therapeutic approach in anorexia. Dismissing feelings, threatening restraints, or stating consequences are nontherapeutic.
The client diagnosed with gastroenteritis is being discharged from the emergency department. Which intervention should the nurse include in the discharge teaching?
- A. If diarrhea persists for more than 96 hours, contact the health-care provider.
- B. Instruct the client to wash hands thoroughly before handling any type of food.
- C. Explain the importance of decreasing steroids gradually as instructed.
- D. Discuss how to collect all stool samples for the next 24 hours.
Correct Answer: B
Rationale: Handwashing prevents the spread of gastroenteritis, a key discharge teaching point. Persistent diarrhea is concerning but less specific, steroids are irrelevant, and stool collection is not routine.