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 A

Explanation

Choice A rationale

Taking prescribed cortisone accurately is crucial for managing multiple sclerosis symptoms. Cortisone is a type of steroid that can reduce inflammation and suppress the immune system, helping to manage MS symptoms.

Choice B rationale

Using a walker when weakness occurs can be beneficial for patients with multiple sclerosis as it can help them maintain mobility and independence. However, it is not the most important instruction for the nurse to include in the discharge teaching plan.

Choice C rationale

Increasing daily intake of sodium in the diet is not recommended for patients with multiple sclerosis. High sodium intake can exacerbate symptoms of multiple sclerosis and may increase the risk of relapses.

Choice D rationale

Avoiding extreme environmental temperatures can be beneficial for patients with multiple sclerosis as heat can worsen symptoms. However, it is not the most important instruction for the nurse to include in the discharge teaching plan.

A. Cefazolin 1 gram intravenously every 6 hours. B. Complete blood cell count (CBC) in the morning. C. Straight catheterization if unable to void. D. Advance from clear liquids as tolerated.

Correct Answer is A

Explanation

The correct answer is A. The nurse should first implement the prescription of Cefazolin 1 gram intravenously every 6 hours.

This is because, on admission of a patient to the postanesthesia care unit (PACU) from surgery, the first priority is to assess the airway and breathing status. Administering Cefazolin, an antibiotic, helps prevent postoperative infections, which is crucial in the immediate postoperative period.

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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

A patient with a history of celiac disease has recently been diagnosed with multiple sclerosis.The nurse is preparing to discharge the patient.What is the most important instruction for the nurse to include in the discharge teaching plan?

Correct Answer is A

Explanation

The nurse is admitting a client from the postanesthesia unit to the postoperative surgical care unit.Which prescription should the nurse implement first?

Correct Answer is A

Explanation

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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?