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Chapter 42: Lower Gastrointestinal Problems Lewis: Medical-Surgical Nursing, 10th Edition A 22-yr-old female patient with an exacerbation of ulcerative colitis is having 15 to 20 stools daily and has excoriated perianal skin. Which patient behavior indi

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Chapter 42: Lower Gastrointestinal Problems Lewis: Medical-Surgical Nursing, 10th Edition A 22-yr-old female patient with an exacerbation of ulcerative colitis is having 15 to 20 stools daily and has excoriated perianal skin. Which patient behavior indicates that teaching regarding maintenance...

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Medical Surgical Nursing

A client asks the nurse why it is important to be weighed every day if he has right-sided
heart failure. What is the nurse's best response?

A) "The hospital requires that all inpatients be weighed daily."
B) "Weight is the best indication that you are gaining or losing fluid."
C) "You need to lose weight to decrease the incidence of heart failure."
D) "Daily weights will help us make sure that you're eating properly." - ANSWERS--B

Daily weights are needed to document fluid retention or fluid loss. One liter of fluid
equals 2.2 pounds.

A client has a deep wound covered with a wet-to-damp dressing. Which intervention
does the nurse include on this client's care plan?

A) Apply a new dressing when the seal breaks and the dressing leaks.
B) Change the dressing when the current dressing is saturated.
C) Leave the dressing intact until next week.
D) Change the dressing every 6 hours around the clock. - ANSWERS--D

Wet-to-damp dressings are changed every 4 to 6 hours to provide maximum
débridement. Synthetic dressings can be left in place for extended periods of time but
need to be changed if the seal breaks and the exudate is leaking. Dry gauze dressings
should be changed when the outer layer becomes saturated.

A client has a small-bore nasoenteric feeding tube. The nurse assesses the following
vital signs: temperature, 100.2° F (37.8° C); pulse, 112 beats/min; respiratory rate, 22
breaths/min; and blood pressure, 106/62 mm Hg. Which action by the nurse takes
priority?

A) Auscultate bowel sounds and slow the feeding down.
B) Remove the tube immediately and notify the heath care provider.
C) Auscultate lung sounds and obtain oxygen saturation.
D) Add blue dye to the feeding tube formula. - ANSWERS--C

The client may have aspirated. The nurse should further assess the client's respiratory
and oxygenation status. The client may have another reason for the abnormal vital

,signs, so the nurse should not pull out the tube before performing other assessments.
Adding blue dye to the tube feeding formula is not recommended to check for
aspiration. Slowing the feeding down will not be helpful.

A client has a urinary tract infection. Which assessment by the nurse is most helpful?

A) Palpating and percussing the kidneys and bladder
B) Performing a bladder scan to assess post-void residual
C) Assessing medical history and current medical problems
D) Inquiring about recent travel to foreign countries - ANSWERS--C

Clients who are severely immune compromised or who have diabetes mellitus are more
prone to fungal urinary tract infection. The nurse should assess for these factors. A
physical examination and a post-void residual may be needed, but not until further
information is obtained. Travel to foreign countries probably would not be as important,
because even if exposed, the client needs some degree of immune compromise to
develop a fungal urinary tract infection.

A client has a wound on his left trochanter that is 4 inches in diameter, with black tissue
at the perimeter, and bone is exposed. Which is the nurse's best action?

A) Document as a stage I pressure ulcer and apply a transparent dressing.
B) Document as a stage II pressure ulcer and start wet-to-dry gauze treatments.
C) Document as a stage IV pressure ulcer and prepare the client for débridement.
D) Document as a stage III pressure ulcer and start antibiotic therapy. - ANSWERS--C

A stage IV ulcer is one in which skin loss is full thickness, with extensive destruction,
tissue necrosis, and/or damage to muscle, bone, or supporting structures. Eschar may
be present. When the bone of the trochanter area is visible, tissue loss includes muscle
loss. A potential intervention consists of débridement of the necrotic tissue and a
possible graft to promote healing.

A client has been admitted to the intensive care unit with worsening pulmonary
manifestations of heart failure. What is the nurse's best action?

A) Administer loop diuretics as prescribed.
B) Begin cardiopulmonary resuscitation (CPR).
C) Promote rest and minimize activities.
D) Place the client in a high Fowler's position. - ANSWERS--A

,The client with worsening heart failure is most at risk for pulmonary edema as a
consequence of fluid retention. Administering diuretics will decrease the fluid overload,
thereby decreasing the incidence of pulmonary edema. High Fowler's position might
help the client breathe easier but will not solve the problem. CPR is not warranted in this
situation. Rest is important for clients with heart failure, but this is not the priority.

A client has been taught to restrict dietary sodium. Which food selection by the client
indicates to the nurse that teaching has been effective?

a. a grilled cheese sandwich with tomato soup
b. Chinese take-out, including steamed rice
c. a chicken leg, one slice of bread with butter, and steamed carrots
d. slices of ham and cheese on whole grain crackers - ANSWERS--C

Clients on restricted sodium diets generally should avoid processed, smoked, and
pickled foods and those with sauces and other condiments. Foods lowest in sodium
include fish, poultry, and fresh produce. The chinese food likely would have soy sauce,
the tomato soup is processed, and the crackers are a snack food - a category of foods
often high in sodium.

A client has newly diagnosed diabetes. To delay the onset of microvascular and
macrovascular complications in this client, the nurse stresses that the client take which
action?

A) Restrict fluid intake.
B) Prevent ketosis.
C) Control hyperglycemia.
D) Prevent hypoglycemia. - ANSWERS--C
Hyperglycemia is a critical factor in the pathogenesis of long-term diabetic
complications. Maintaining tight glycemic control will help delay the onset of
complications. Preventing hypoglycemia and ketosis, although important, is not as
important as maintaining daily glycemic control. Restricting fluid intake is not part of the
treatment plan for clients with diabetes.

A client has recently been placed on prednisone (Deltasone). What is the highest
priority instruction the nurse will provide?

A) "Take the drug with food or milk."
B) "Report any abdominal pain or dark-colored vomit."
C) "Expect to experience weight gain."

, D) "Watch your diet while on this medication." - ANSWERS--B

All of these directions are appropriate to give the client; however, telling the client to
report abdominal pain and dark-colored vomit is most important because these could
signal gastric ulceration.

A client is admitted with infection and a high fever. Which assessments by the nurse
take priority? (Select all that apply.)

A) Skin turgor
B) Pulse quality
C) Blood pressure
D) Bowel sounds
E) Respiratory effort
F) Mental status - ANSWERS--A, B, C, F
Dehydration can accompany fever, especially if the client is sweating profusely. Blood
pressure, pulse quality, and skin turgor are assessments of fluid status. Mental status
changes can accompany fluid losses, especially in older clients.

A client is admitted with left lower lung pneumonia. Which assessment finding does the
nurse correlate with this condition?

A) Expiratory wheeze on the right side
B) Crackles heard on expiration bilaterally
C) Dullness to percussion on the lower left side
D) Crepitus of the skin around the left lung - ANSWERS--C

The client with pneumonia may have dullness to percussion on the affected side. The
other options are all inconsistent with pneumonia.

A client is being treated for dehydration. Which statement made by the client indicates
understanding of this condition?

a. I will use a salt substitute when making and eating my meals.
b. I must drink a quart of water or other liquid each day.
c. I will not drink liquids after 6 PM so I won't have to get up at night.
d. I will weigh myself each morning before I eat or drink. - ANSWERS--D

Because 1 L of water weighs 1 kg, change in body weight is a good measure of excess
fluid loss or fluid retention. Weight loss greater than 0.5 lb daily is indicative of

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Chapter 42: Lower Gastrointestinal Problems Lewis: Medical-Surgical Nursing, 10th Edition A 22-yr-old female patient with an exacerbation of ulcerative colitis is having 15 to 20 stools daily and has excoriated perianal skin. Which patient behavior indi

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