Chapter 59: Care of Patients with Noninflammatory Intestinal Disorders Nursing School Test Banks

Chapter 59: Care of Patients with Noninflammatory Intestinal Disorders

Test Bank

MULTIPLE CHOICE

1. A client has irritable bowel syndrome. Which menu selections by this client indicate good understanding of dietary teaching?

a.

Tuna salad on white bread, cup of applesauce, glass of diet cola

b.

Broiled chicken with brown rice, steamed green beans, glass of apple juice

c.

Grilled cheese sandwich, small ripe banana, cup of hot tea with lemon

d.

Grilled steak, green beans, dinner roll with butter, cup of coffee with cream

ANS: B

Clients with irritable bowel syndrome are advised to eat a high-fiber diet (30 to 40 grams a day), with 8 to 10 cups of liquid daily. This selection has the highest fiber content. They should avoid alcohol, caffeine, and other gastric irritants.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Nursing Process (Evaluation)

2. The nurse is performing a physical examination on a client. Which assessment finding leads the nurse to check the clients abdomen for the presence of an acquired umbilical hernia?

a.

Body mass index (BMI) of 41.9

b.

Cholecystectomy last year

c.

History of irritable bowel syndrome

d.

Daily dose of lansoprazole (Prevacid) 30 mg orally

ANS: A

This type of hernia is associated with obesity. The other assessment findings do not place the client at increased risk for an acquired umbilical hernia.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

3. The nurse notes a bulge in a clients groin that is present when the client stands and disappears when the client lies down. Which conclusion does the nurse draw from these assessment findings?

a.

Reducible inguinal hernia

b.

Indirect umbilical hernia

c.

Strangulated ventral hernia

d.

Incarcerated femoral hernia

ANS: A

In a reducible hernia, the contents of the hernial sac can be replaced into the abdominal cavity by gentle pressure or by lying flat. The contents of irreducible, strangulated, or incarcerated hernias may not be replaced into the abdomen when the client lies down.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Analysis)

4. The nurse is caring for a client with an umbilical hernia who reports increased abdominal pain, nausea, and vomiting. The nurse notes high-pitched bowel sounds. Which conclusion does the nurse draw from these assessment findings?

a.

Bowel obstruction; client should be placed on NPO status.

b.

Perforation of the bowel; client needs emergency surgery.

c.

Adhesions in the hernia; client needs elective surgery.

d.

Hernia is dangerously enlarged; client needs a nasogastric (NG) tube.

ANS: A

The client with a hernia presenting with abdominal pain, fever, tachycardia, nausea and vomiting, and hypoactive bowel sounds should be suspected of having developed strangulation. Strangulation poses a risk of intestinal obstruction. The client should be placed on NPO status, and the health care provider should be notified. The symptoms are not suggestive of enlargement of the hernia, adhesion formation, or bowel perforation.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Analysis)

5. The nurse is teaching a client how to use a truss for a femoral hernia. Which statement by the client indicates the need for further teaching?

a.

I will put on the truss before I go to bed each night.

b.

I will put some powder under the truss to avoid skin irritation.

c.

The truss will help my hernia because I cant have surgery.

d.

If I have abdominal pain, I will let my health care provider know right away.

ANS: A

The client is instructed to apply the truss before arising, not before going to bed at night. The other statements show accurate knowledge in using a truss.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Nursing Process (Evaluation)

6. The nurse is providing preoperative teaching for a client who will undergo herniorrhaphy surgery. Which instruction does the nurse give to the client?

a.

Eat a low-residue diet for the first week after surgery.

b.

Change the dressing every day until the staples are removed.

c.

Take acetaminophen (Tylenol) 1000 mg every 4 hours for pain.

d.

Cough and deep breathe every 2 hours for the first week after surgery.

ANS: B

The dressing should be changed every day until the staples are removed, so the client can check the incision for signs of infection. Constipation is common following hernia surgery, so clients should include adequate amounts of fiber in the diet. The maximum daily dosage of Tylenol is 4000 mg. Taking 1000 mg of Tylenol every 4 hours means that intake is 6000 mg/day, which could cause toxicity and liver damage. The client should change positions and take deep breaths to facilitate lung expansion but should avoid coughing, which can place stress on the incision line.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Teaching/Learning

7. The nurse is performing a physical assessment for a client who underwent a hemorrhoidectomy the previous day. The nurse notes that the client has lower abdominal distention accompanied by dullness to percussion over the distended area. Which is the nurses priority action?

a.

Assess the clients vital signs.

b.

Determine the last time the client voided.

c.

Insert a rectal tube to facilitate passage of flatus.

d.

Document the findings in the clients chart.

ANS: B

Assessment findings indicate that the client may have an overfull bladder. In the immediate postoperative period, the client may experience difficulty voiding owing to urinary retention. A rectal tube should not be inserted for a client who had a hemorrhoidectomy the previous day. The clients vital signs may be checked after the nurse determines the clients last void. The nurse should document all findings and actions in the clients medical record.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Implementation)

8. The nurse is screening clients at a community health fair. Which client is at highest risk for development of colorectal cancer?

a.

Young adult who drinks eight cups of coffee every day

b.

Middle-aged client with a history of irritable bowel syndrome

c.

Older client with a BMI of 19.2 who works 65 hours per week

d.

Older client who travels extensively and eats fast food frequently

ANS: D

Colon cancer is rare before the age of 40, but its incidence increases rapidly with advancing age. Fast food tends to be high in fat and low in fiber, increasing the risk for colon cancer. Irritable bowel syndrome, a heavy workload, and coffee intake do not increase the risk for colon cancer. A BMI of 19.2 is within normal limits.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 1246

TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)

MSC: Integrated Process: Nursing Process (Assessment)

9. The nurse is performing a physical assessment of a client with a new diagnosis of colorectal cancer. The nurse notes the presence of visible peristaltic waves and, on auscultation, hears high-pitched bowel sounds. Which conclusion does the nurse draw from these findings?

a.

The tumor has metastasized to the liver and biliary tract.

b.

The tumor has caused an intussusception of the intestine.

c.

The growing tumor has caused a partial bowel obstruction.

d.

The client has developed toxic megacolon from the growing tumor.

ANS: C

The presence of visible peristaltic waves, accompanied by high-pitched or tingling bowel sounds, is indicative of partial obstruction caused by the tumor. Assessment findings do not indicate metastasis to the liver, intussusception of the intestine, or toxic megacolon.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Analysis)

10. The nurse is caring for a client who is scheduled to have fecal occult blood testing. Which instructions does the nurse give to the client?

a.

You must fast for 12 hours before the test.

b.

You will be given a cleansing enema the morning of the test.

c.

You must avoid eating meat for 48 hours before the test.

d.

You will be sedated and will require someone to accompany you home.

ANS: C

The client is instructed to avoid meat, aspirin, vitamin C, and anti-inflammatory drugs for 48 hours before the test. The other directions are not accurate for this test.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 1247

TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)

MSC: Integrated Process: Teaching/Learning

11. A client who has had fecal occult blood testing tells the nurse that the test was negative for colon cancer and wishes to cancel a colonoscopy scheduled for the next day. Which is the nurses best response?

a.

I will call and cancel the test for tomorrow.

b.

You need two negative fecal occult blood tests.

c.

This does not rule out the possibility of colon cancer.

d.

You should wait at least a week to have the colonoscopy.

ANS: C

A negative result does not completely rule out the possibility of colon cancer. To determine whether the client has colon cancer, a colonoscopy should be performed, so the entire colon can be visualized and a tissue sample taken for biopsy. The client need not wait a week before the colonoscopy. Two negative fecal occult blood tests do not rule out the presence of colorectal cancer (CRC).

DIF: Cognitive Level: Comprehension/Understanding REF: p. 1247

TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)

MSC: Integrated Process: Teaching/Learning

12. The nurse is caring for a client who has been newly diagnosed with colon cancer. The client has become withdrawn from family members. Which strategy does the nurse use to assist the client at this time?

a.

Ask the health care provider for a psychiatric consult for the client.

b.

Explain the improved prognosis for colon cancer with new treatment.

c.

Encourage the client to verbalize feelings about the diagnosis.

d.

Allow the client to remain withdrawn as long as he or she wishes.

ANS: C

The nurse recognizes that the client may be expressing feelings of grief. The nurse should encourage the client to verbalize feelings and identify fears to move the client through the phases of the grief process. A psychiatric consult is not appropriate for the client. The nurse should not brush aside the clients feelings with a generalization about cancer prognosis and treatment. The nurse should not ignore the clients withdrawal behavior.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)

MSC: Integrated Process: Caring

13. The nurse is caring for a client with colon cancer and a new colostomy. The client wishes to talk with someone who had a similar experience. Which is the nurses best response?

a.

Most people who have had a colostomy are reluctant to talk about it.

b.

I will make a referral to the United Ostomy Associations of America.

c.

You can get all the information you need from the enterostomal therapist.

d.

I do not think that we have any other clients with colostomies on the unit right now.

ANS: B

Nurses need to become familiar with community-based resources to assist clients better. The local chapter of the United Ostomy Associations of America has resources for clients and their families, including Ostomates (specially trained visitors who also have ostomies). Although the enterostomal therapist is an expert in ostomy care, talking with him or her is not the same as talking with someone who actually has had a colostomy. Many people are willing to share their ostomy experience in the hope of helping others. The nurse should not brush aside the clients request by saying that no colostomy clients are present on the unit at the time.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 1253

TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareReferrals) MSC: Integrated Process: Caring

14. The nurse is caring for a client who has suffered abdominal trauma in a motor vehicle crash. Which laboratory finding indicates that the clients liver was injured?

a.

Serum lipase, 49 U/L

b.

Serum amylase, 68 IU/L

c.

Serum creatinine, 0.8 mg/dL

d.

Serum transaminase, 129 IU/L

ANS: D

The level of serum transaminase, a liver enzyme, is elevated with liver trauma. The other laboratory values are within normal limits and are not specific for the liver.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialLaboratory Values) MSC: Integrated Process: Nursing Process (Analysis)

15. The nurse is caring for a client who is brought to the emergency department following a motor vehicle crash. The nurse notes that the client has ecchymotic areas across the lower abdomen. Which is the priority action of the nurse?

a.

Measure the clients abdominal girth.

b.

Assess for abdominal guarding or rigidity.

c.

Check the clients hemoglobin and hematocrit.

d.

Ask whether the client was riding in the front or back seat of the car.

ANS: B

On noticing the ecchymotic areas, the nurse should check to see if abdominal guarding or rigidity is present; this could indicate major organ injury. The nurse should then notify the provider. Measuring abdominal girth or asking about seating in the car is not appropriate at this time. Laboratory test results can be checked after assessment for abdominal guarding or rigidity.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareEstablishing Priorities)

MSC: Integrated Process: Nursing Process (Implementation)

16. A client tells the nurse that her husband is repulsed by her colostomy and refuses to be intimate with her after surgery. Which is the nurses best response?

a.

Lets talk to the ostomy nurse to help you and your husband work through this.

b.

You could try to wear longer lingerie that will better hide the ostomy appliance.

c.

You should empty the pouch first so it will be less noticeable for your husband.

d.

If you are not careful, you can hurt the stoma if you engage in sexual activity.

ANS: A

The nurse should collaborate with the ostomy nurse to help the client and her husband work through intimacy issues. The nurse should not minimize the clients concern about her husband with ways to hide the ostomy. The client will not hurt the stoma by becoming intimate with her husband.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)

MSC: Integrated Process: Caring

17. The nurse is caring for a client who just had colon resection surgery with a new colostomy. Which teaching objective does the nurse include in the clients plan of care?

a.

Understanding colostomy care and lifestyle implications

b.

Learning how to change the appliance independently

c.

Demonstrating the correct way to change the appliance by discharge

d.

Not being afraid to handle the ostomy appliance tomorrow

ANS: C

Client learning goals must be measurable and objective with a time frame, so the nurse can determine whether they have been met. When the goal is to have the client demonstrate a particular skill, the nurse can easily determine whether the goal was met. The specific time frame of by discharge is easily measurable also. The other goals are all subjective and cannot be measured objectively. The first two options do not have time frames. Tomorrow is a vague time frame.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Teaching/Learning

18. The nurse is caring for a client who has been diagnosed with a bowel obstruction. Which assessment finding leads the nurse to conclude that the obstruction is in the small bowel?

a.

Potassium of 2.8 mEq/L, with a sodium value of 121 mEq/L

b.

Losing 15 pounds over the last month without dieting

c.

Reports of crampy abdominal pain across the lower quadrants

d.

High-pitched, hyperactive bowel sounds in all quadrants

ANS: A

Small bowel obstructions often lead to severe fluid and electrolyte imbalances. The client is hypokalemic (normal range, 3.5 to 5.0 mEq/L) and hyponatremic (normal range, 136 to 145 mEq/L). Dramatic weight loss without dieting followed by bowel obstruction leads to the probable development of colon cancer. High-pitched, hyperactive bowel sounds may be noted with large and small bowel obstructions. Crampy abdominal pain across the lower quadrants is associated with large bowel obstruction.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Analysis)

19. A client post-hemorrhoidectomy feels the need to have a bowel movement. Which action by the nurse is best?

a.

Have the client use the bedside commode.

b.

Stay with the client, providing privacy.

c.

Make sure toilet paper and the call light are in reach.

d.

Plan to send a stool sample to the laboratory.

ANS: B

The first bowel movement after hemorrhoidectomy can be painful enough to induce syncope. The nurse should stay with the client. The nurse should instruct clients who are discharged the same day to have someone nearby when they have their first postoperative bowel movement. Making sure needed items are within reach is an important nursing action too, but it does not take priority over client safety. The other two actions are not needed in this situation.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlAccident/Injury Prevention)

MSC: Integrated Process: Nursing Process (Implementation)

20. A client is brought to the emergency department after being shot in the abdomen and is hemorrhaging heavily. Which action by the nurse is the priority?

a.

Draw blood for type and crossmatch.

b.

Start two large IVs for fluid resuscitation.

c.

Obtain vital signs and assess skin perfusion.

d.

Assess and maintain a patent airway.

ANS: D

All options are important nursing actions in the care of a trauma client. However, airway always comes first. The client must have a patent airway, or other interventions will not be helpful.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareEstablishing Priorities)

MSC: Integrated Process: Nursing Process (Implementation)

21. A client with a mechanical bowel obstruction reports that abdominal pain, which was previously intermittent and colicky, is now more constant. Which is the priority action of the nurse?

a.

Measure the abdominal girth.

b.

Place the client in a knee-chest position.

c.

Medicate the client with an opioid analgesic.

d.

Assess for bowel sounds and rebound tenderness.

ANS: D

A change in the nature and timing of abdominal pain in a client with a bowel obstruction can signal peritonitis or perforation. The nurse should immediately check for rebound tenderness and the absence of bowel sounds. The nurse need not measure abdominal girth. The nurse may help the client to the knee-chest position for comfort, but this is not the priority action. The nurse should not medicate the client until the physician has been notified of the change in his or her condition.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Assessment)

22. The nurse is teaching self-care measures for a client who has hemorrhoids. Which nursing intervention does the nurse include in the plan of care for the client?

a.

Instruct the client to use dibucaine (Nupercainal) ointment whenever needed.

b.

Teach the client to choose low-fiber foods to make bowels move more easily.

c.

Tell the client to take his or her time on the toilet when needing to defecate.

d.

Encourage the client to dab with moist wipes instead of wiping with toilet paper.

ANS: D

The client should be instructed to use wet wipes and dab the anal area after defecating to avoid further irritation. Dibucaine can be used only for short periods of time because long-term use can mask worsening symptoms. Clients with hemorrhoids require high-fiber foods. The client should not be encouraged to strain at stool or to spend long periods of time on the toilet, because this increases pressure in the rectal area, which can make hemorrhoids worse.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Teaching/Learning

23. The nurse is caring for a client who is to receive 5-fluorouracil (5-FU) chemotherapy IV for the treatment of colon cancer. Which assessment finding leads the nurse to contact the health care provider?

a.

White blood cell (WBC) count of 1500/mm3

b.

Presence of fatigue with a headache

c.

Presence of slight nausea and no appetite

d.

Two diarrhea stools yesterday

ANS: A

Common side effects of 5-FU include fatigue, leukopenia, diarrhea, mucositis and mouth ulcers, and peripheral neuropathy. However, the clients WBC count is very low (normal range, 5000 to 10,000/mm3), so the provider should be notified. He or she may want to delay chemotherapy by a day or two. Certainly the client is at high risk for infection. The other assessment findings are consistent with common side effects of 5-FU that would not need to be reported immediately.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Diagnostic Tests/Treatments/Procedures)

MSC: Integrated Process: Nursing Process (Analysis)

24. A client who has had a colostomy placed in the ascending colon expresses concern that the effluent collected in the colostomy pouch has remained liquid for 2 weeks after surgery. Which is the nurses best response?

a.

This is normal for your type of colostomy.

b.

I will let the health care provider know, so that it can be assessed.

c.

You should add extra fiber to your diet to stop the diarrhea.

d.

Your stool will become firmer over the next few weeks.

ANS: A

The stool from an ascending colostomy can be expected to remain liquid because little large bowel is available to reabsorb the liquid from the stool. The provider may be notified, but this is not the best response from the nurse. Liquid stool from an ascending colostomy will not become firmer with the addition of fiber to the clients diet or with the passage of time.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Teaching/Learning

25. A middle-aged male client has irritable bowel syndrome that has not responded well to diet changes and bulk-forming laxatives. He asks the nurse about the new drug lubiprostone (Amitiza). What information does the nurse provide him?

a.

This drug is investigational right now for irritable bowel syndrome.

b.

Unfortunately, this drug is approved only for use in women.

c.

Lubiprostone works well only in a small fraction of irritable bowel cases.

d.

Lets talk to your health care provider about getting you a trial prescription.

ANS: B

Lubiprostone (Amitiza) is approved only for use in women. The other statements are not accurate.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesExpected Actions/Outcomes) MSC: Integrated Process: Teaching/Learning

26. The nurse is caring for a client who has undergone removal of a benign colonic polyp. The client asks the nurse why a follow-up colonoscopy is necessary. Which is the nurses best response?

a.

You are at risk for developing more polyps in the future.

b.

You may have other cancerous lesions that could not be seen right now.

c.

The doctor can remove only a few of the polyps during each colonoscopy.

d.

This test will ensure that you have healed where the polyp was removed.

ANS: A

Once a person has developed a polyp, risk for occurrence of multiple polyps is present. The physician usually can remove all visible polyps during the colonoscopy procedure. Follow-up colonoscopy is not done to ensure that healing occurred where a polyp was removed, or to check for cancerous lesions that were not visible during the first procedure.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 1260

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Teaching/Learning

MULTIPLE RESPONSE

1. The nurse is helping a student prepare to insert a nasogastric tube for an adult client with a bowel obstruction. Which actions by the student indicate to the nurse that a review of the procedure is needed? (Select all that apply.)

a.

Gathering supplies, including an 8 Fr Levin tube, sterile gloves, tape, and water-soluble lubricant

b.

Performing hand hygiene and positioning the client in high Fowlers position, with pillows behind the head and shoulders

c.

Attaching a 60-mL irrigation syringe to the end of the nasogastric tube before inserting it into the nose

d.

Instructing the client to extend the neck against the pillow once the nasogastric tube has reached the oropharynx

e.

Checking for correct placement by checking the pH of the fluid aspirated from the tube

f.

Securing the nasogastric tube by taping it to the clients nose and pinning the end to the pillowcase

g.

Connecting the nasogastric tube to intermittent medium suction with an anti-reflux valve on the air vent

ANS: A, D, F

An 8 Fr nasogastric tube is too small for drainage of thick stomach contents. Sterile gloves are not needed for the procedure. The tube should be secured to the clients gown, not to the pillowcase, because it could become dislodged easily. The clients head should be flexed forward once the tube has reached the oropharynx. All the other actions are appropriate. A 60-mL irrigation syringe should be attached to the end of the tube before insertion so that gastric fluid does not erupt from the tube when it enters the stomach.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Diagnostic Tests/Treatments/Procedures)

MSC: Integrated Process: Nursing Process (Implementation)

2. The nurse is providing discharge teaching for a client who has undergone colon resection surgery with a colostomy. Which statements by the client indicate that the instruction was understood? (Select all that apply.)

a.

I will change the ostomy appliance daily and as needed.

b.

I will use warm water and a soft washcloth to clean around the stoma.

c.

I will start bicycling and swimming again once my incision has healed.

d.

I will notify the doctor right away if any bleeding from the stoma occurs.

e.

I will check the stoma regularly to make sure that it stays a deep red color.

f.

I will avoid dairy products to reduce gas and odor in the pouch.

g.

I will cut the flange so it fits snugly around the stoma to avoid skin breakdown.

ANS: B, C, G

The client should avoid using soap to clean around the stoma because it might prevent effective adhesive of the ostomy appliance. The client should use warm water and a soft washcloth instead. The stoma should remain a soft pink color. A deep red or purple hue indicates ischemia and should be reported to the surgeon right away. The tissue of the stoma is very fragile, and scant bleeding may occur when the stoma is cleaned. Yogurt and buttermilk can help reduce gas in the pouch, so the client need not avoid dairy products. Exercise (other than some contact sports) is important for clients with an ostomy.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Nursing Process (Evaluation)

COMPLETION

1. A client is to receive 12 mg/kg of 5-fluorouracil (5-FU) chemotherapy IV for treatment of colon cancer. The client weighs 132 lb. The client will receive ______ milligrams of 5-FU.

ANS:

720

132 lb = 60 kg

60 kg 12 mg/kg = 720 mg

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesDosage Calculation)

MSC: Integrated Process: Nursing Process (Implementation)

Leave a Reply