The nurse anticipates that Loren will describe her diarrhea as…
Bloody
Because rectal bleeding is a common finding in ulcerative colitis, which additional question is important for the nurse to ask Loren?
“Do you feel fatigued or light-headed?”
What is the nurse’s best response to this information?
“Ulcerative colitis can cause problems in areas other than the colon.”
Which instruction(s) are important for the nurse to provide Loren regarding food and fluid intake during the stool specimen collection? (Select all that apply.)
-Avoid red meat.
-Do not take supplemental ascorbic acid (Vitamin C).
-Do not take supplemental ascorbic acid (Vitamin C).
Which explanation of the procedure for the barium enema should the nurse provide Loren?
X-ray is used to visualize the large intestine after barium is instilled.
What instruction should the nurse provide to a client who just completed a barium enema?
Drink extra fluids.
Immediately following the sigmoidoscopy, it is important for the nurse to assess for which manifestation?
Abdominal guarding
In responding to Loren, the nurse recognizes that Loren’s remarks reflect which of Erikson’s developmental stages?
Intimacy versus isolation
What is the nurse’s best response to Loren?
“This all seems very overwhelming right now.”
What instruction should the nurse provide Loren?
“You need to increase the length of time between each dose of the medication.”
Which assessment finding indicates that the Lomotil is having the desired effect?
Decreased number of bowel movements.
What instruction is most important to include when teaching Loren about the prednisone?
Monitor mouth sores for white patches or increased discomfort.
To maintain this diet, which snack choice is best for Loren?
Angel food cake and cranberry juice.
Which additional serum lab value best reflects nutritional malabsorption?
Albumin 1.5 g/dL
Since the course of TPN treatment will last about 10 days, the nurse plans to prepare Loren for the insertion of which access device?
Multi-lumen subclavian catheter
What action should the nurse take?
Administer insulin using a sliding scale protocol
Which medication that Loren is receiving is most likely to contribute to her increased blood glucose level?
Prednisone (Deltasone)
The TPN is available in a 1000 mL bag and is prescribed to run at 60 mL per hour. The nurse will expect to hang a new bag in approximately how many hours?
17
What action should the nurse take after the remaining TPN has infused?
Hang a liter of 10% dextrose in water at the same rate of infusion.
To ensure that Loren remains infection free, which responsibility is best to delegate to an unlicensed assistive personnel (UAP)?
Obtain and record vital signs every 4 hours
In providing the care, which division of tasks is best for the nurse to assign?
After the RN removes the subclavian catheter, the LPN obtains vital signs, and the UAP transports the tip to the lab.
The nurse recognizes this complication of ulcerative colitis as:
Toxic megacolon
The nurse expects to alter Loren’s oral intake in what way?
Loren should be NPO.
What action should the nurse take?
Administer the dose as scheduled concurrently with the IV fluids.
The nurse recognizes that the UAP is protected under what legal statute?
Civil Rights Legislation.
What action should the nurse take?
Instruct the UAP to document all the alleged offenses in writing and submit a copy to the supervisor.
With whom should the nurse advise the UAP to collaborate?
A legal aid clinic attorney.
How should the nurse respond?
“The drainage will become thicker and appear more yellow or yellow-brown.”
To ensure the best skin protection around the stoma, the nurse should instruct Loren to use what type of product?
Pectin-based solid skin barrier.
When should Loren expect to empty her pouch?
When the pouch is 1/3 to 1/2 full.
