A client with a history of Crohn's disease presents to the outpatient clinic complaining of abdominal pain and diarrhea. The client reports passing stools with blood and mucus. Which interventions should the nurse prioritize? Select all that apply

Monitor the client's intake and output.

Check the client's temperature

Evaluate the client's skin integrity.

Ensure the client increases intake to make up for nutrients lost.

Ambulate the client a minimum of two times a day.

Answer and Explanation

Correct Answer : A,B,C

An acute exacerbation of Crohn's disease involves intensified transmural inflammation, leading to ulceration and bleeding. The presence of blood and mucus in the stool indicates active mucosal injury. Nursing priorities center on assessing for systemic complications such as dehydration, sepsis, and localized tissue breakdown, as these patients are at high risk for electrolyte imbalances and infection during a flare.

Rationale:

A. Monitoring intake and output is a priority because the client is experiencing diarrhea. Frequent liquid stools can lead to rapid dehydration and significant electrolyte depletion. Accurately tracking fluid balance is essential for determining the need for intravenous fluid replacement and for monitoring the patient's overall hemodynamic and renal status during the exacerbation.

B. Checking the client's temperature is a priority to screen for sepsis or abscess formation. Crohn's disease can lead to intestinal perforations or fistulas that introduce bacteria into the peritoneum or bloodstream. An elevated temperature often indicates an acute infection that requires immediate medical intervention with antibiotics and further diagnostic imaging.

C. Evaluating skin integrity is a priority because frequent diarrhea and the presence of blood or mucus are highly irritating to the perianal skin. The moisture and enzymes in the stool can cause rapid skin breakdown and excoriation. Early intervention with barrier creams and meticulous hygiene is necessary to prevent painful ulcers and secondary localized infections.

D. Encouraging the client to increase intake during an acute flare may be counterproductive. Often, the bowel needs to be placed at rest (NPO status) to reduce inflammation and decrease the frequency of painful bowel movements. Nutritional needs are important, but during an acute phase, aggressive oral feeding can worsen abdominal pain and diarrhea.

E. Ambulating the client is not a priority during an acute inflammatory flare. While general mobility is good for preventing venous stasis, a patient with severe diarrhea and abdominal pain needs rest to conserve energy and reduce intestinal motility. The focus must be on physical stabilization and symptom management rather than forced physical activity.

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Correct Answer is C

Explanation

An ileostomyinvolves the surgical creation of an opening into the ileum, bypassing the entire colon. The resulting stoma must be vibrant and moist, reflecting adequate microvascular perfusion. Any compromise in the arterial supply or venous drainage of the stoma can lead to tissue necrosisand ischemia, making visual inspection of the stoma the most critical postoperative nursing assessment for viability.

Rationale:

A.A sweetish odor from ileostomy output is not a clinical emergency and can be influenced by diet or medications. While changes in odor are worth noting for the patient's comfort, they do not indicate a life-threatening complication. Odor management is a secondary concern compared to the physical integrity and blood supply of the newly created stoma.

B.While it is true that an ileostomy pouch must be worn at all times because the output is continuous and liquid, this is a lifestyle and hygiene instruction. It does not address the immediate surgical safety of the patient. The most important information must always prioritize the detection of acute physiological failure, such as the loss of blood flow.

C.Calling the provider if the stoma is bluish or pale is the most important instruction because it indicates ischemiaor infarction. A healthy stoma should be beefy red or pink, signifying adequate oxygenation. A color change to blue, purple, or pale signifies a lack of blood perfusion, which is a surgical emergency requiring immediate intervention to save the tissue.

D.Describing the initial postoperative output is helpful for setting expectations, but it is a normal finding rather than a warning sign of a complication. Dark green liquid is common as the bowel begins to function. While the patient should know this is normal, the priority of teaching must always be focused on identifying abnormal, dangerous changes in stoma health.

A. 8 hours B. 10 hours 15 minutes C. 25 hours D. 29 hours

Correct Answer is C

Explanation

Intravenous insulin therapyrequires precise calculation to maintain glycemic control and prevent complications like hypoglycemia or diabetic ketoacidosis. Regular insulin is the only type used for IV infusion due to its predictable pharmacokinetics. Calculating the infusion durationis essential for pharmacy coordination and ensuring continuous delivery of this high-alert medication to the patient through an infusion pump.

Rationale:

A.8 hours is an incorrect calculation based on the provided dosage and volume. If the bag lasted only 8 hours at 4 units per hour, the total units delivered would be only 32 units. This does not account for the 100 units contained in the supplied 100 mL IV bag, leading to a significant error in estimating the duration of the medication supply.

B.10 hours 15 minutes is mathematically incorrect for this scenario. This figure does not correspond to any standard calculation using the 100 unit/100 mL concentration provided in the order. Accurate medication timing is vital for nursing staff to ensure that a new bag is ready before the current one is depleted, preventing interruptions in insulin delivery.

C.25 hours is the correct duration for the infusion. Calculation: Step 1: Determine the concentration of the bag, which is 100 units / 100 mL = 1 unit per mL. Step 2: Determine the hourly volume to be infused: 4 units per hour / 1 unit per mL = 4 mL per hour. Step 3: Calculate the total time: 100 mL total volume / 4 mL per hour = 25 hours.

D.29 hours is an incorrect result and does not reflect the units-to-volume ratio provided in the order. Inaccurately calculating the infusion time can lead to poor planning in the clinical setting. The simple 1:1 ratio of units to milliliters in this specific IV bag clearly indicates that at 4 units per hour, the 100 mL bag will last exactly 25 hours.

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A client with a history of Crohn's disease presents to the outpatient clinic complaining of abdominal pain and diarrhea. The client reports passing stools with blood and mucus. Which interventions should the nurse prioritize? Select all that apply

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is teaching a client about caring for a new ileostomy. What information is most important to include?

Correct Answer is C

Explanation

Physician order says ”Infuse Regular Insulin at 4 units/hr". You’re supplied with an IV bag of the prescribed medication that reads" 100 units per 100 mE’. How many hours will it take for this IV bag to infuse?

Correct Answer is C

Explanation

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