chapter 45

Question 1

1. The nurse is caring for a client who has watery, incontinent diarrhea and has diagnosed
   with Clostridium difficile. Which of the following actions should the nurse include in the
   plan of care?
   a. Order a diet with no dairy products for the client.
   b. Place the client in a private room with contact isolation.
   c. Teach the client about why antibiotics are not being used.
   d. Educate the client about proper food handling and storage.

Answer 1

B
Because C. difficile is highly contagious, the client should be placed in a private room and
contact precautions should be used. There is no need to restrict dairy products for this type
of diarrhea. Metronidazole is frequently used to treat C. difficile. Improper food handling
and storage do not cause C. difficile.

Question 2

A client 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 client to increase oral fluid intake.
b. Inform the client that a daily bowel movement is unnecessary.
c. Assess the client about individual risk factors for constipation.
d. Suggest that the client increase dietary intake of high-fibre foods.

Answer 2

C
The nurse’s initial action should be further assessment of the client for risk factors for
constipation and for usual bowel pattern. The other actions may be appropriate but will be
based on the assessment.

Question 3

The nurse is teaching a client who has chronic 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.

Answer 3

D
A high fluid intake is needed when clients 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 client 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.

Question 4

The nurse is obtaining a history for a female client who is being evaluated for acute lower
abdominal pain and vomiting. Which of the following questions is most useful in
determining the cause of the client’s symptoms?
a. “Is it possible that you are pregnant?”
b. “Can you tell me more about the pain?”
c. “What type of foods do you usually eat?”
d. “What is your usual elimination pattern?”

Answer 4

B
A complete description of the pain provides clues about the cause of the problem. The
usual diet and elimination patterns are less helpful in determining the reason for the
client’s symptoms. Although the nurse should ask whether the client is pregnant to
determine whether the client might have an ectopic pregnancy and before any radiology
studies are done, this information is not the most useful in determining the cause of the
pain.

Question 5

The nurse is caring for a client who had an exploratory laparotomy with a resection of a
short segment of small bowel two days previously. The client has gas pains and abdominal
distension. Which of the following nursing actions is best to take at this time?
a. Give a return-flow enema.
b. Assist the client to ambulate.
c. Administer the ordered IV morphine sulphate.
d. Insert the ordered promethazine suppository.

Answer 5

B
Ambulation will improve peristalsis and help the client eliminate flatus and reduce gas
pain. Morphine will further reduce peristalsis. A return-flow enema may decrease the
client’s symptoms, but ambulation is less invasive and should be tried first. Promethazine
is used as an antiemetic rather than to decrease gas pains or distension.

Question 6

The nurse is caring for a client who has blunt abdominal trauma after an automobile
accident and severe pain. A peritoneal lavage returns brown drainage with fecal material.
Which of the following actions should the nurse plan to take next?
a. Auscultate the bowel sounds.
b. Prepare the client for surgery.
c. Check the client’s oral temperature.
d. Obtain information about the accident.

Answer 6

B
Return of brown drainage and fecal material suggests perforation of the bowel and the
need for immediate surgery. Auscultation of bowel sounds, checking the temperature, and
obtaining information about the accident are appropriate actions, but the priority is to
prepare to send the client for emergency surgery.

Question 7

The nurse is admitting a client for evaluation of right lower quadrant abdominal pain with
nausea and vomiting and an O2 saturation of 90%. Which of the following actions should
the nurse take?
a. Check for rebound tenderness.
b. Assist the client to cough and deep breathe.
c. Administer oxygen via nasal cannula.
d. Encourage the client to take sips of clear liquids.

Answer 7

: C
The client’s clinical manifestations are consistent with appendicitis but the main priority is
to administer oxygen as the O2 saturation is only 90%. The client should be NPO in case
immediate surgery is needed. Checking for rebound tenderness frequently is unnecessary
and uncomfortable for the client. The client will need to know how to cough and deep
breathe postoperatively, but coughing will increase pain at this time.

Question 8

Which of the following nursing actions should be included in the plan of care for a male
client with bowel irregularity and a new diagnosis of irritable bowel syndrome (IBS)?
a. Encourage the client to express feelings and ask questions about IBS.
b. Suggest that the client increase the intake of milk and other dairy products.
c. Educate the client about the use of Tegaserod to reduce symptoms.
d. Teach the client to avoid using nonsteroidal anti-inflammatory drugs (NSAIDs).

Answer 8

A
Because psychological and emotional factors can affect the symptoms for IBS,
encouraging the client to discuss emotions and ask questions is an important intervention.
Tegaserod (Zelnorm) has been recently used to treat women with IBS whose primary
bowel symptom is constipation however this question is asking about a male client.
Although yogourt may be beneficial, milk is avoided because lactose intolerance can
contribute to symptoms in some clients. NSAIDs can be used by clients with IBS.

Question 9

The nurse is caring for a client 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 client on NPO status.
b. Administer IV metoclopramide.
c. Teach the client about total colectomy surgery.
d. Administer cobalamin injections.

Answer 9

A
An initial therapy for an acute exacerbation of inflammatory bowel disease (IBD) is to rest
the bowel by making the client NPO. Cobalamin (vitamin B12) is absorbed in the ileum,
which is not affected by ulcerative colitis. Although total colectomy is needed for some
clients, there is no indication that this client is a candidate. Metoclopramide increases
peristalsis and will worsen symptoms.

Question 10

The nurse is admitting a client 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.

Answer 10

B
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 client 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.

Question 11

The nurse is teaching a client with ulcerative colitis about sulphasalazine. Which of the
following client statements indicates that the teaching has been effective?
a. “I will need to take this medication for at least one year.”
b. “I will need to avoid contact with people who are sick.”
c. “The medication will need to be tapered if I need surgery.”
d. “The medication will prevent infections that cause the diarrhea.”

Answer 11

A
Sulphasalazine usually has a maintenance dose that the client takes for one year. It is not
used to treat infections. Sulphasalazine does not reduce immune function. Unlike
corticosteroids, tapering of sulphasalazine is not needed.

Question 12

The nurse is caring for a client with an exacerbation of ulcerative colitis who is having
15–20 stools daily and has external hemorrhoids. Which of the following client behaviours
indicate that teaching regarding maintenance of skin integrity has been effective?
a. The client uses incontinence briefs to contain loose stools.
b. The client asks for antidiarrheal medication after each stool.
c. The client uses witch hazel compresses to decrease anal discomfort.
d. The client cleans the perianal area with soap and water after each stool.

Answer 12

C
Witch hazel compresses are suggested to reduce anal irritation and discomfort.
Incontinence briefs may trap diarrhea and increase the incidence of skin breakdown.
Antidiarrheal medications are not given 15–20 times a day. The perianal area should be
washed with plain water after each stool.

Question 13

The nurse is providing client teaching about recommended dietary choices for a client with
an acute exacerbation of inflammatory bowel disease (IBD). Which of the following diet
choices by the client indicates a need for more teaching?
a. Scrambled eggs
b. White toast and jam
c. Oatmeal with cream
d. Pancakes with syrup

Answer 13

C
During acute exacerbations of IBD, the client should be on a low-residue diet and avoid
high-fibre foods such as whole grains. High-fat foods also may cause diarrhea in some
clients. The other choices are low residue and would be appropriate for this client.

Question 14

The nurse is caring for a client who has had a total proctocolectomy and permanent
ileostomy who tells the nurse, “I cannot bear to even look at the stoma. I do not think I can
manage all these changes.” Which of the following actions is best?
a. Develop a detailed written plan for ostomy care for the client.
b. Ask the client more about the concerns with stoma management.
c. Reassure the client that care for the ileostomy will become easier.
d. Postpone any client teaching until the client adjusts to the ileostomy.

Answer 14

B
Encouraging the client to share concerns assists in helping the client adjust to the body
changes. Acknowledgement of the client’s feelings and concerns is important rather than
offering false reassurance. Because the client indicates that the feelings about the ostomy
are the reason for the difficulty with the many changes, development of a detailed ostomy
care plan will not improve the client’s ability to manage the ostomy. Although detailed
ostomy teaching may be postponed, the nurse should offer teaching about some aspects of
living with an ostomy.

Question 15

The nurse is caring for a client 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

Answer 15

A
Medications are used to induce and maintain remission in clients with inflammatory bowel
disease (IBD). Decreased activity level is indicated only if the client has severe fatigue
and weakness. Fluids are needed to prevent dehydration. There is no advantage to enteral
feedings.

Question 16

The nurse is caring for a client 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 client?
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

Answer 16

B
Fistulas between the bowel and bladder occur in Crohn’s disease and can lead to UTI.
There is no information indicating that the client’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 client’s urine indicate that a fistula has occurred.

Question 17

The nurse is caring for a client 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 client?
a. Referred back pain
b. Metabolic alkalosis
c. Projectile vomiting
d. Abdominal distension

Answer 17

D
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.

Question 18

The nurse is preparing a 50-year-old client for an annual physical examination. Which of
the following diagnostic tests should the nurse teach to the client?
a. Endoscopy
b. Fecal occult blood test
c. Computerized tomography screening
d. Carcinoembryonic antigen (CEA) testing

Answer 18

B
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.

Question 19

The nurse is conducting preoperative preparation for a client scheduled for an
abdominal-perineal resection. Which of the following actions should the nurse implement?
a. Give IV antibiotics starting 24 hours before surgery to reduce the number of bowel
bacteria.
b. Teach the client that activities such as sitting at the bedside will be started the first
postoperative day.
c. Instruct the client that another surgery in 8–12 weeks will be used to create an
ileal-anal reservoir.
d. Administer polyethylene glycol lavage solution (GoLYTELY) to ensure that the
bowel is empty before the surgery.

Answer 19

D
A bowel-cleansing agent is used to empty the bowel before surgery to reduce the risk for
infection. Oral antibiotics (rather than IV antibiotics) are given to reduce colonic and rectal
bacteria. Sitting is contraindicated after an abdominal-perineal resection. A permanent
colostomy is created with this surgery.

Question 20

Before undergoing a colon resection for cancer of the colon, a client has an elevated
carcinoembryonic antigen (CEA) test. Which of the following explanations should the
nurse provide to the client 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.

Answer 20

B
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.

Question 21

. Which of the following nursing actions is most important to include in the plan of care for
a client 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.

Answer 21

C
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 client will be encouraged to assist with the colostomy, but this is not the
highest priority in the immediate postoperative period.

Question 22

During the initial postoperative assessment of a client’s stoma formed from a transverse
colostomy, the nurse finds it to be deep pink with moderate edema and a small amount of
bleeding. Which of the following actions should the nurse take based upon these findings?
a. Document the stoma assessment.
b. Monitor the stoma every 30 minutes.
c. Notify the surgeon about the stoma appearance.
d. Place an ice pack on the stoma to reduce swelling.

Answer 22

A
The stoma appearance indicates good circulation to the stoma. There is no indication that
surgical intervention is needed or that frequent stoma monitoring is required. Swelling of
the stoma is normal for 2–3 weeks after surgery, and an ice pack is not needed.

Question 23

The nurse is caring for a client who has ulcerative colitis and a proctocolectomy and
ileostomy. Which of the following information should the nurse include in client teaching?
a. Restrict fluid intake to prevent constant liquid drainage from the stoma.
b. Use care when eating high-fibre foods to avoid obstruction of the ileum.
c. Irrigate the ileostomy daily to avoid having to wear a drainage appliance.
d. Change the pouch every day to prevent leakage of contents onto the skin.

Answer 23

B
High-fibre foods are introduced gradually and should be well chewed to avoid obstruction
of the ileostomy. Clients with ileostomies lose the absorption of water in the colon and
need to take in increased amounts of fluid. The pouch should be drained frequently but is
changed every 5–7 days. The drainage from an ileostomy is liquid and continuous, so
control by irrigation is not possible.

Question 24

The nurse is providing discharge teaching for a client with a new colostomy. Which of the
following client actions indicates that the teaching has been effective?
a. Empties the colostomy bag once it is 2/3 full.
b. Drinks at least 1 000 mL of fluid a day.
c. Contacts the health care provider if there is pain or erythema in the peristomal
area.
d. Takes acetaminophen when a temperature of 38.3°C (100.9°F) occurs.

Answer 24

C
The health care provider should be contacted if there is pain or erythema in the peristomal
area. If the client has a temperature, the health care provider should be contacted. The
colostomy should be emptied before it becomes 1/3 full. The client should drink at least
1 500–2 000 mL per day to avoid dehydration.

Question 25

The nurse is providing teaching to a client with a new ileostomy. Which of the following
daily drainage amounts should the nurse inform the client is expected after the bowel
adjusts to the ileostomy?
a. 400 mL
b. 600 mL
c. 800 mL
d. 1 000 mL

Answer 25

C
After the proximal small bowel adapts to reabsorb more fluid, the average amount of
ileostomy drainage is about 800 mL daily.

Question 26

Which of the following actions should the nurse implement when initiating the initial plan
of care for a client admitted with acute diverticulitis?
a. Give stool softeners.
b. Administer IV fluids.
c. Order a diet high in fibre and fluids.
d. Prepare the client for colonoscopy.

Answer 26

B
A client 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 softeners, are usually given, and these will be implemented later in the
hospitalization. The client with acute diverticulitis will not have a colonoscopy because of
the risk for perforation and peritonitis.

Question 27

The nurse is providing discharge teaching for a client who has had a herniorrhaphy to
repair an incarcerated inguinal hernia. Which of the following information should be
included in the teaching?
a. Encourage the client to cough.
b. Provide sitz baths several times daily.
c. Avoid use of acetaminophen for pain.
d. Apply a scrotal support and encourage deep breathing.

Answer 27

D
A scrotal support is used to reduce discomfort and deep breathing, but coughing is not
encouraged. Coughing will increase pressure on the incision. Sitz baths will not relieve
pain and would not be of use after this surgery. Acetaminophen can be used for
postoperative pain.

Question 28

After the nurse has completed teaching a client with newly diagnosed celiac disease,
which of the following breakfast choices by the client indicates good understanding of the
information?
a. Corn tortilla with eggs
b. Bagel with cream cheese
c. Oatmeal with non-fat milk
d. Whole wheat toast with butter

Answer 28

A
Avoidance of gluten-containing foods is the only treatment for celiac disease. Corn does
not contain gluten, while oatmeal and wheat do.

Question 29

Which of the following instructions should the nurse include in discharge teaching for a
client who has had a hemorrhoidectomy at an outpatient surgical centre?
a. Maintain a low-residue diet until the surgical area is healed.
b. Use ice packs on the perianal area to relieve pain and swelling.
c. Take prescribed pain medications before a bowel movement is expected.
d. Delay having a bowel movement for several days until healing has occurred.

Answer 29

C
Bowel movements may be very painful, and clients may avoid defecation unless pain
medication is taken before the bowel movement. Delay of bowel movements is likely to
lead to constipation. A high-residue diet will increase stool bulk and prevent constipation.
Sitz baths are used to relieve pain and keep the surgical area clean.

Question 30

A client calls the clinic and tells the nurse about a new onset of severe and frequent,
diarrhea. Which of the following actions should the nurse anticipate for this client?
a. Collect a stool specimen.
b. Prepare for colonoscopy.
c. Schedule a barium enema.
d. Have blood cultures drawn.

Answer 30

A
Acute diarrhea is usually caused by an infectious process and stool specimens are obtained
for culture and examined for parasites or white blood cells. There is no indication that the
client needs a colonoscopy, blood cultures, or a barium enema.

Question 31

The nurse is caring for a client with Crohn’s disease who has megaloblastic anemia.
Which of the following medications should the nurse anticipate teaching the client about
taking on an ongoing basis?
a. Oral ferrous sulphate tablets
b. Regular blood transfusions
c. Iron dextran (Imferon) infusion
d. Cobalamin (B12) nasal spray or injections

Answer 31

D
Crohn’s disease frequently affects the ileum, where absorption of cobalamin occurs, and it
must be administered regularly by nasal spray or IM to correct the anemia. Iron deficiency
does not cause megaloblastic anemia. The client may need occasional transfusions but not
regularly scheduled transfusions.

Question 32

The nurse is performing an admission assessment for a client with abdominal pain and
palpates the left lower quadrant and the client indicates right lower quadrant pain. Which
of the following descriptors should the nurse use to document this finding?
a. Rebound pain
b. Cullen sign
c. Rovsing sign
d. McBurney point

Answer 32

C
Rovsing sign occurs when palpation of the left lower quadrant causes pain in the right
lower quadrant. McBurney point, rebound pain, and Cullen sign are used to describe other
aspects of the abdominal assessment.

Question 33

The nurse is caring for a critically ill client who develops incontinence of watery stools.
What of the following actions is best for the nurse to take to prevent complications
associated with ongoing incontinence?
a. Insert a rectal tube.
b. Use incontinence briefs.
c. Apply a perianal pouch.
d. Assist the client to a bedside commode at frequent intervals.

Answer 33

C
Perianal pouching is an alternative in the management of fecal incontinence. Rectal tubes
are avoided because of possible damage to the anal sphincter and ulceration of the rectal
mucosa. Incontinence briefs may be helpful but, unless they are changed frequently, are
likely to increase the risk for skin breakdown. A critically ill client will not be able to use
the commode.

Question 34

The nurse is interviewing a client with abdominal pain and possible irritable bowel
syndrome. Which of the following questions is most important for the nurse to ask?
a. “Have you been passing a lot of gas?”
b. “What foods affect your bowel patterns?”
c. “Do you have any abdominal distension?”
d. “How long have you had abdominal pain?”

Answer 34

D
One criterion for the diagnosis of irritable bowel syndrome (IBS) is the presence of
abdominal discomfort or pain for at least 3 months. Abdominal distension, flatulence, and
food intolerance also are associated with IBS, but are not diagnostic criteria.

Question 35

Which of the following prescribed interventions should the nurse implement first when
caring for a client who has just diagnosed with peritonitis caused by a ruptured
diverticulum?
a. Administer morphine sulphate 4 mg IV.
b. Infuse metronidazole 500 mg IV.
c. Send the client for a computerized tomography scan.
d. Insert a nasogastric (NG) tube and connect it to intermittent low suction.

Answer 35

B
Since peritonitis can be fatal if treatment is delayed, the initial action should be to start
antibiotic therapy (after any ordered cultures are obtained). The other actions can be done
after antibiotic therapy is initiated

Question 36

Which of the following actions should the nurse take first when a client calls the clinic
complaining of diarrhea of 24 hours’ duration?
a. Ask the client to describe the character of the stools and any associated symptoms.
b. Inform the client that laboratory testing of blood and stool specimens will be
necessary.
c. Suggest that the client drink clear liquid fluids with electrolytes, such as Gatorade
or Pedialyte.
d. Advise the client to use over-the-counter loperamide to slow gastrointestinal (GI)
motility.

Answer 36

A
The initial response by the nurse should be further assessment of the client. The other
responses may be appropriate, depending on what is learned in the assessment.

Question 37

A client is admitted to the emergency department with severe abdominal pain with
rebound tenderness. The vital signs include temperature 38.3°C (100.9°F), pulse 130,
respirations 34, and blood pressure (BP) 84/50. Which of the following interventions
should the nurse implement first?
a. Administer IV ketorolac 5 mg.
b. Draw blood for a complete blood count (CBC).
c. Obtain a computed tomography (CT) scan of the abdomen.
d. Infuse 1 000 mL of lactated Ringer’s solution over 30 minutes.

Answer 37

D
The priority for this client is to treat the client’s hypovolemic shock with fluid infusion.
The other actions should be implemented after starting the fluid infusion.

Question 38

The nurse is caring for a client following an exploratory laparotomy and bowel resection
who has a nasogastric tube to suction and symptoms of nausea and stomach distension.
Which of the following actions should the nurse take first?
a. Auscultate for hypotonic bowel sounds.
b. Notify the client’s health care provider.
c. Reposition the tube and check for placement.
d. Remove the tube and replace it with a new one.

Answer 38

C
Repositioning the tube will frequently facilitate drainage. Because this is a common
occurrence, it is not appropriate to notify the health care provider. Information about the
presence or absence of bowel tones will not be helpful in improving drainage. Removing
the tube and replacing it are unnecessarily traumatic to the client.

Question 39

A client is brought to the emergency department with a knife impaled in the abdomen
following a domestic fight. During the initial assessment of the client, which of the
following actions should the nurse implement?
a. Assess the BP and pulse.
b. Remove the knife to assess the wound.
c. Determine the presence of Rovsing sign.
d. Insert a urinary catheter and assess for hematuria.

Answer 39

A
The initial assessment is focused on determining whether the client has hypovolemic
shock. The knife should not be removed until the client is in surgery, where bleeding can
be controlled. Rovsing sign is assessed in the client with suspected appendicitis. A client
with a knife in place will be taken to surgery and assessed for bladder trauma there.

Question 40

A client with ulcerative colitis who is taking azathioprine calls the nurse in the outpatient
clinic about all of these symptoms. Which of the following symptoms is most important to
communicate to the health care provider?
a. Nausea
b. Joint pain
c. Frequent headaches
d. Elevated temperature

Answer 40

D
Since azathioprine suppresses immune function, rapid treatment of infection is essential.
The other client complaints are common adverse effects of the medication, but do not
indicate any potentially life-threatening complications.

Question 41

The nurse is interviewing a 40-year-old client and obtains information about the following
client problems. Which of the following information is most important to communicate to
the health care provider?
a. The client had an appendectomy at age 17.
b. The client smokes a pack/day of cigarettes.
c. The client has a history of frequent constipation.
d. The client has recently noticed blood in the stools.

Answer 41

D
Blood in the stools is a possible clinical manifestation of colorectal cancer and requires
further testing by the health care provider. The other client information also will be
communicated to the health care provider, but does not indicate an urgent need for further
testing or intervention

Question 42

When assessing the colour of a new stoma in the postoperative period, which of the
following findings should cause the nurse to suspect anemia?
a. Light red to rose
b. Pale pink
c. Blanching, dark red to purple
d. Dark red

Answer 42

B
A pale pink stoma indicates anemia. A light red rose or dark red brick colour indicates a
viable stoma mucosa. A blanching dark red to purple stoma may indicate inadequate blood
supply to the stoma, low flow state, excessive tension on the bowel mesentery at the time
of construction, or venous congestion; usually occurs in the first 72 hour after surgery

Question 43

The nurse is caring for a client who has been taking antibiotics for several days and
develops watery diarrhea. Which of the following actions should the nurse take first?
a. Notify the health care provider.
b. Obtain a stool specimen for analysis.
c. Provide education about handwashing.
d. Place the client on contact precautions.

Answer 43

D
The client’s history and new onset diarrhea suggest a C. difficile infection, which requires
implementation of contact precautions to prevent spread of the infection to other clients.
The other actions also are appropriate but can be accomplished after contact precautions
are implemented.

Question 44

After receiving change-of-shift report, which of the following clients should the nurse
assess first?
a. A client whose new ileostomy has drained 800 mL over the previous 8 hours
b. A client with familial adenomatous polyposis who has occult blood in the stool
c. A client with ulcerative colitis who has had six liquid stools in the previous 4 hours
d. A client who has abdominal distension and an apical heart rate of 136 beats/minute

Answer 44

D
The client’s abdominal distension and tachycardia suggest hypovolemic shock caused by
problems such as peritonitis or intestinal obstruction, which will require rapid intervention.
The other clients also should be assessed as quickly as possible, but the data do not
indicate any life-threatening complications associated with their diagnoses.

Question 45

A client with a gunshot wound to the abdomen undergoes surgery, and a colostomy is
formed as illustrated. Which of the following information should the nurse include in
client teaching?
a. This type of colostomy is usually temporary.
b. Soft, formed stool can be expected as drainage.
c. Stool will be expelled from both ostomy stomas.
d. Irrigations can regulate drainage from the stomas.

Answer 45

A
A loop, or double-barrel stoma, is usually temporary. Stool will be expelled from the
proximal stoma only. The stool from the transverse colon will be liquid and regulation
through irrigations will not be possible.