Nokea
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.
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The nurse is preparing a 50-year-old patient for an annual physical examination. Which of the following diagnostic tests should the nurse teach to the patient?
- A. Endoscopy
- B. Fecal occult blood test
- C. Computerized tomography screening
- D. Carcinoembryonic antigen (CEA) testing
Correct Answer: B
Rationale: At age 50, individuals with an average risk for colorectal cancer (CRC) should begin screening for CRC, including a fecal occult blood test (FOBT). Colonoscopy is the gold standard for CRC screening. The other diagnostic tests are not recommended as part of a routine annual physical examination at age 50.
The nurse is admitting a patient with an exacerbation of inflammatory bowel disease (IBD). Which of the following nursing actions should the nurse include in the plan of care?
- A. Restrict oral fluid intake.
- B. Monitor stools for blood.
- C. Increase dietary fibre intake.
- D. Ambulate four times daily.
Correct Answer: B
Rationale: Since anemia or hemorrhage may occur with IBD, stools should be assessed for the presence of blood. The other actions would not be appropriate for the patient with IBD. Because dietary fibre may increase gastrointestinal (GI) motility and exacerbate the diarrhea, severe fatigue is common with IBD exacerbations, and dehydration may occur.
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
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.
The nurse is caring for a patient with an acute exacerbation of ulcerative colitis having 14-16 bloody stools a day and crampy abdominal pain associated with the diarrhea. Which of the following actions should the nurse take?
- A. Place the patient on NPO status.
- B. Administer IV metoclopramide.
- C. Teach the patient about total colectomy surgery.
- D. Administer cobalamin injections.
Correct Answer: A
Rationale: An initial therapy for an acute exacerbation of inflammatory bowel disease (IBD) is to rest the bowel by making the patient NPO. Cobalamin (vitamin B12) is absorbed in the ileum, which is not affected by ulcerative colitis. Although total colectomy is needed for some patients, there is no indication that this patient is a candidate. Metoclopramide increases peristalsis and will worsen symptoms.