A client with a history of inflammatory bowel disease develops severe ulcerative colitis and is admitted to the intensive care unit after surgery for a fistula repair.
Which intervention is most important for the nurse to include in the plan of care?

Turn every 2 hours around the clock from side-to-side.

Assess skin condition and turgor for breakdown.

Record the amount of daily wound drainage.

Replace fluids IV based on intake and output.

Answer and Explanation

The Correct Answer is D

Choice D rationale

In a patient with severe ulcerative colitis who has undergone surgery for a fistula repair, replacing fluids IV based on intake and output is the most important intervention to include in the plan of care. This is because patients with ulcerative colitis often experience significant fluid and electrolyte imbalances due to diarrhea and other gastrointestinal losses. Following surgery, these imbalances can be further exacerbated by factors such as fasting, surgical stress, and the use of certain medications. Therefore, careful monitoring of fluid and electrolyte balance, and appropriate IV fluid replacement, is crucial to prevent complications such as dehydration, electrolyte imbalances, and renal dysfunction.

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Correct Answer is B

Explanation

Choice A rationale

Encouraging the client to drink at least 3 to 4 liters of water prior to the procedure is not a standard preparation for an intravenous pyelogram (IVP). Overhydration could potentially complicate the procedure.

Choice B rationale

It is essential for the nurse to notify the healthcare provider if the client reports any allergies to iodine or shellfish. The contrast dye used in an IVP often contains iodine. People who are allergic to iodine or shellfish may have a reaction to this dye.

Choice C rationale

Instructing the client to keep the legs straight for 6 to 8 hours after the procedure is not a standard instruction for IVP. This instruction is more commonly associated with procedures involving the insertion of a catheter into a large artery or vein.

Choice D rationale

Inserting an indwelling urinary catheter prior to going to the X-ray department is not a standard preparation for an IVP. The procedure involves the injection of a contrast dye into a vein, not the bladder.

A. Print the electronic medical record (EMR) from the backup server. B. Wait for notification that the system has been rebooted. C. Identify information as a late entry in the record. D. Notify the information services department of the situation.

Correct Answer is D

Explanation

Choice A rationale

Printing the electronic medical record (EMR) from the backup server may not be the most immediate action required. While having a backup of the EMR is important, it does not address the immediate issue of the system failure.

Choice B rationale

Waiting for notification that the system has been rebooted is a passive approach and may not be the most effective initial action. It does not address the immediate need to communicate the issue to the appropriate department.

Choice C rationale

Identifying information as a late entry in the record is a documentation practice that is used when charting is not completed in a timely manner. However, this action does not address the immediate issue of the system failure.

Choice D rationale

Notifying the information services department of the situation is the correct action. This allows the appropriate department to begin troubleshooting and resolving the issue. In the event of a system failure, the first step should be to report the issue so that it can be addressed as quickly as possible.

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A client with a history of inflammatory bowel disease develops severe ulcerative colitis and is admitted to the intensive care unit after surgery for a fistula repair.Which intervention is most important for the nurse to include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When preparing a client for an intravenous pyelogram (IVP), it is essential for the nurse to take which action?

Correct Answer is B

Explanation

After a scheduled downtime, the computer documentation system fails to restart.What should be the nurse’s initial action?

Correct Answer is D

Explanation

A healthcare provider prescribes a low-fiber diet for a patient with ulcerative colitis.Which food selection by the patient indicates to the nurse that the patient understands the prescribed diet?

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Which of the following symptoms reported by a patient taking lovastatin should the nurse prioritize for immediate follow-up?

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A client with a history of inflammatory bowel disease develops severe ulcerative colitis and is admitted to the intensive care unit after surgery for a fistula repair.
Which intervention is most important for the nurse to include in the plan of care?