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 C
Explanation
Choice A rationale
While the supervisor of the neurology unit may have expertise in neurology, they are not typically responsible for coordinating the progression of a patient’s care following a spinal cord injury.
Choice B rationale
The nurse in charge of risk management is typically responsible for identifying and evaluating risks in the healthcare setting. They are not typically involved in the direct management of a patient’s care.
Choice C rationale
The nurse case manager is specifically trained to coordinate and manage the care of patients with complex conditions, including spinal cord injuries. They work with the patient, family, and healthcare team to develop a comprehensive care plan.
Choice D rationale
While an adult nurse practitioner can provide a high level of care, they are not typically responsible for managing the progression of a patient’s care following a spinal cord injury.
Correct Answer is D
Explanation
Choice A rationale
While substituting natural fruit juices for carbonated drinks can be a healthy dietary change, it is not directly related to the patient’s reported symptoms of severe pain and inability to bear weight on the right ankle.
Choice B rationale
Avoiding the consumption of wine, beer, and coffee can have various health benefits, but it is not directly related to the patient’s current symptoms. Furthermore, there is no indication in the patient’s history that these beverages are contributing to the patient’s condition.
Choice C rationale
Using an electric heating pad when pain is at its worst can provide temporary relief, but it does not address the underlying issue causing the pain. Additionally, heat therapy is not typically recommended for acute gout attacks, which could be a potential cause of the patient’s symptoms given their history of gouty arthritis.
Choice D rationale
Encouraging active range of motion can help to limit stiffness and improve joint function, which could potentially alleviate the patient’s pain and improve their ability to bear weight on the right ankle. This advice is relevant to the patient’s symptoms and medical history.
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