A nurse is assisting with the care of a client.

Exhibits

Data Collection Findings.

For each data collection finding, click to specify if the finding is consistent with: ulcerative colitis, diverticulitis, or Crohn's disease.

Each finding may support more than 1 disease process.

Abdominal cramping

Weight loss

Diarrhea

Anemia

Answer and Explanation

The Correct Answer is {"A":{"answers":"A,B,C"},"B":{"answers":"A,C"},"C":{"answers":"A,C"},"D":{"answers":"A,C"}}

The data collection findings are consistent with the following disease processes: Abdominal cramping: This finding can indicate ulcerative colitis, diverticulitis, or Crohn’s disease.

Abdominal cramping is a common symptom of inflammation and infection in the digestive tract. Weight loss: This finding can indicate ulcerative colitis or Crohn’s disease. Weight loss can result from malabsorption, reduced appetite, inflammation, or complications of the disease. Diarrhea: This finding can indicate ulcerative colitis or Crohn’s disease. Diarrhea is caused by increased intestinal motility, inflammation, and ulceration of the mucosa. Anemia: This finding can indicate ulcerative colitis or Crohn’s disease. Anemia can result from chronic blood loss, iron deficiency, vitamin B12 deficiency, or inflammation. The finding of fatty appearance and foul odor of the stool is also consistent with Crohn’s disease, as it suggests steatorrhea (excess fat in the stool) due to malabsorption. The finding of a positive fecal occult blood test is consistent with ulcerative colitis or Crohn’s disease, as it indicates bleeding in the digestive tract.

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Correct Answer is D

Explanation

Choice A rationale:

Tape the tube to the child's cheek. Taping the tube to the child's cheek is not the recommended method for securing a gastrostomy enteral tube. It can cause discomfort and skin irritation for the child. Proper securing methods involve using specialized tube holders or dressings designed for this purpose.

Choice B rationale:

Apply water-soluble lubricant to the site. Rationale: Applying a water-soluble lubricant to the site is not a standard practice for gastrostomy tube care. It is essential to keep the site clean and dry to prevent infection. Lubricants are not typically used in this context.

Choice C rationale:

Attaching an extension tube is related to administering feedings or medications rather than the maintenance and care of the gastrostomy site. Site care focuses on protecting the skin and ensuring cleanliness around the tube insertion area.

Choice D rationale:

Apply a skin barrier protectant to the site. Using a skin barrier protectant helps shield the peristomal skin from irritation and breakdown caused by gastric contents and formula leakage.

A. "I will need to give you Rh(D) immune globulin because you are Rh positive.” B. "You will need to have an empty bladder for the test.” C. "You will have to lie on your left side during the test.” D. "You will have to drink 50 grams of oral glucose before the test.”

Correct Answer is B

Explanation

Choice A rationale:

The administration of Rh(D) immune globulin (RhoGAM) is typically indicated for Rh-negative mothers who are carrying Rh-positive fetuses to prevent sensitization to Rh antigens. It is not directly related to the amniocentesis procedure. Therefore, this information is not necessary for the client undergoing an amniocentesis.

Choice B rationale:

This is the correct answer. Having an empty bladder is crucial during an amniocentesis procedure because a full bladder can obscure visualization of the fetus and the needle placement. It is essential for a successful and safe procedure. The nurse should instruct the client to empty their bladder before the test.

Choice C rationale:

The position during an amniocentesis is typically dorsal recumbent or semi-Fowler's position to allow for proper visualization of the fetus and needle placement. Lying on the left side is not a standard position for this procedure, so this information is incorrect and not necessary for the client.

Choice D rationale:

Drinking 50 grams of oral glucose is not a requirement for an amniocentesis procedure. This information is unrelated to the amniocentesis and can be confusing for the client. Therefore, it is not necessary to include this in the instructions.

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A nurse is assisting with the care of a client. Exhibits Data Collection Findings. For each data collection finding, click to specify if the finding is consistent with: ulcerative colitis, diverticulitis, or Crohn's disease. Each finding may support more than 1 disease process.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing site care for a child who has a gastrostomy enteral tube. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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A nurse is assisting with the care of a client.

Exhibits

Data Collection Findings.

For each data collection finding, click to specify if the finding is consistent with: ulcerative colitis, diverticulitis, or Crohn's disease.

Each finding may support more than 1 disease process.