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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
Choice A rationale
The material should not be written at a twelfth-grade reading level. Older adults may have varying levels of literacy, and health information should be accessible to all. It is recommended that patient education materials be written at a sixth-grade reading level or lower.
Choice B rationale
Using a 12-point type font can make the material easier to read, especially for older adults who may have vision problems.
Choice C rationale
Including a list with definitions of unfamiliar terms can help older adults understand the material better. Medical jargon can be confusing, and clear explanations of these terms can improve comprehension.
Choice D rationale
Pictures can help illustrate complex ideas and make the material more engaging and easier to understand. Visual aids can be particularly helpful when explaining how to take medication or demonstrating exercises.
Choice E rationale
Using common words with few syllables can make the material more accessible. Complex medical terms can be confusing, and using simple language can help ensure that the information is understood.
Correct Answer is A
Explanation
Choice A rationale
Osteoarthritis is a joint disease in which the tissues in the joint, including the cartilage, break down over time. The degradation of joint cartilage is the primary pathological condition that leads to the symptoms of osteoarthritis, such as increased pain and stiffness.
Choice B rationale
A systemic inflammatory response is not the primary cause of osteoarthritis. While inflammation can occur in the affected joint, osteoarthritis is not a systemic inflammatory disease like rheumatoid arthritis.
Choice C rationale
An infectious process in the synovial fluid is not typically associated with osteoarthritis. Infections can lead to a different type of arthritis known as septic arthritis.
Choice D rationale
A decrease in bone mineral density is associated with osteoporosis, not osteoarthritis. In osteoarthritis, the issue is primarily with the degradation of cartilage, not a loss of bone density.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.