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
Explanation
Choice A rationale
While fresh fruits and vegetables are part of a healthy diet, they are not specifically recommended for the prevention of osteoporosis. They do not contain significant amounts of calcium, which is crucial for bone health.
Choice B rationale
Low fat dairy products are a good source of calcium, which is essential for bone health and the prevention of osteoporosis.
Choice C rationale
While water and herbal teas can contribute to overall hydration, they do not contain significant amounts of calcium or vitamin D, which are crucial for bone health.
Choice D rationale
While iron-rich meats contribute to overall health, they do not contain significant amounts of calcium or vitamin D, which are crucial for bone health.
Correct Answer is ["3742"]
Explanation
Step 1 is: Convert the child’s weight from pounds to kilograms. 1 pound is approximately 0.453592 kilograms, so 55 lb × 0.453592 kg/lb = 24.9476 kg.
Step 2 is: Calculate the total daily dosage. 150 mg/kg/day × 24.9476 kg = 3742.14 mg/day. Therefore, the nurse should administer approximately 3742 mg each day when rounded to the nearest whole number.
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