Nokea
Which of the following actions should the nurse implement when initiating the initial plan of care for a patient admitted with acute diverticulitis?
- A. Give stool softeners.
- B. Administer IV fluids.
- C. Order a diet high in fibre and fluids.
- D. Prepare the patient for colonoscopy.
Correct Answer: B
Rationale: A patient with acute diverticulitis will be NPO and given parenteral fluids. A diet high in fibre and fluids will be implemented before discharge. Bulk-forming laxatives, rather than stool
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The nurse is teaching a patient who has persistent constipation, about the use of psyllium. Which of the following information should the nurse include?
- A. Absorption of fat-soluble vitamins may be reduced by fibre-containing laxatives.
- B. Dietary sources of fibre should be eliminated to prevent excessive gas formation.
- C. Use of this type of laxative to prevent constipation does not cause adverse effects.
- D. Large amounts of fluid should be taken to prevent impaction or bowel obstruction.
Correct Answer: D
Rationale: A high fluid intake is needed when patients are using bulk-forming laxatives to avoid worsening constipation. Although bulk-forming laxatives are generally safe, the nurse should emphasize the possibility of constipation or obstipation if inadequate fluid intake occurs. Although increased gas formation is likely to occur with increased dietary fibre, the patient should gradually increase dietary fibre and eventually may not need the psyllium. Fat-soluble vitamin absorption is blocked by stool softeners and lubricants, not by bulk-forming laxatives.
The nurse is admitting a patient for evaluation of right lower quadrant abdominal pain accompanied by nausea and vomiting. On assessment the temperature is 37.5°C (99.5°F), heart rate 105, respiratory rate 20 and an O2 saturation of 90%. Which of the following actions should the nurse take?
- A. Check for rebound tenderness.
- B. Assist the patient to cough and deep breathe.
- C. Administer oxygen via nasal cannula.
- D. Encourage the patient to take sips of clear liquids.
Correct Answer: C
Rationale: The patient's clinical manifestations are consistent with appendicitis but the main priority is to administer oxygen as the O2 saturation is only 90%. The patient should be NPO in case immediate surgery is needed. Checking for rebound tenderness frequently is unnecessary and uncomfortable for the patient. The patient will need to know how to cough and deep breathe postoperatively, but coughing will increase pain at this time.
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.
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.
The nurse is caring for a patient with Crohn's disease who develops a fever and symptoms of a urinary tract infection (UTI) with tan, fecal-smelling urine. Which of the following information should the nurse teach the patient?
- A. To clean the perianal area carefully after any stools
- B. About fistula formation between the bowel and bladder
- C. To empty the bladder before and after sexual intercourse
- D. About the effects of corticosteroid use on immune function
Correct Answer: B
Rationale: Fistulas between the bowel and bladder occur in Crohn's disease and can lead to UTI. There is no information indicating that the patient's risk for UTI is caused by poor cleaning or not voiding before and after intercourse. Steroid use may increase the risk for infection, but the characteristics of the patient's urine indicate that a fistula has occurred.