A nurse is attending to a client who has just been admitted due to an acute exacerbation of ulcerative colitis. What should be the nurse’s initial course of action?

Investigate the client’s emotional concerns.

Check the client’s perianal skin integrity.

Obtain a dietary history from the client.

Review the client’s electrolyte values.

Answer and Explanation

The Correct Answer is B

Choice A rationale
While emotional concerns are important to address in a holistic care approach, they are not the initial course of action when a client is admitted due to an acute exacerbation of ulcerative colitis. Emotional concerns are usually addressed once the client’s physical condition is stabilized.
Choice B rationale
Checking the client’s perianal skin integrity is a crucial initial step when a client is admitted due to an acute exacerbation of ulcerative colitis. Ulcerative colitis can cause rectal bleeding and diarrhea, which can lead to skin breakdown in the perianal area. Therefore, assessing for skin integrity helps in early detection and management of potential skin complications.
Choice C rationale
Obtaining a dietary history from the client is important but not the initial course of action in this scenario. Dietary history is usually obtained once the client’s condition is stabilized and when planning for discharge or dietary modifications.
Choice D rationale
Reviewing the client’s electrolyte values is important in managing ulcerative colitis, but it’s not the initial course of action. Electrolyte imbalances can occur due to diarrhea and

malabsorption, which are common in ulcerative colitis. However, this is usually done after initial physical assessments and stabilization of the client.

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Correct Answer is D

Explanation

Choice A rationale
Documenting the bowel sounds as hypoactive is not the most appropriate action. Hypoactive bowel sounds are fewer than three bowel sound events in a minute or none at all. However, the absence of bowel sounds does not necessarily mean they are hypoactive. It could be due to other reasons such as ileus.
Choice B rationale
Administering prescribed drugs for constipation is not the immediate course of action when the nurse doesn’t hear any gurgling while listening to bowel sounds. Constipation is a condition that can cause hypoactive bowel sounds, but it’s not the only reason for the absence of bowel sounds. The nurse should first confirm the absence of bowel sounds before considering this action.
Choice C rationale

Reviewing dietary intake for the past 24 hours is not the immediate course of action. While diet can affect bowel sounds, it’s not the first step when bowel sounds are not heard. The nurse should first confirm the absence of bowel sounds before considering this action.
Choice D rationale
The correct action when the nurse doesn’t hear any gurgling while listening to bowel sounds is to continue to listen for at least another 60 seconds. Bowel sounds are produced by the movement of fluid, gas, and contents through the intestines. An absence of bowel sounds for greater than two minutes may indicate that there is no peristalsis—which implies an ileus.
Therefore, the nurse should continue to listen for at least another 60 seconds to confirm the absence of bowel sounds.

A. Auscultation of bruit over pedal pulse. B. Groin tenderness. C. Pallor in the affected extremity. D. Cramping pain in one foot.

Correct Answer is B

Explanation

Choice A rationale
Auscultation of a bruit over the pedal pulse is not a typical symptom of DVT. A bruit is a sound heard over an artery due to turbulent blood flow. While it may indicate vascular disease, it is not a symptom of DVT121314.
Choice B rationale
Groin tenderness can be a symptom of DVT. DVT often causes pain or tenderness in the affected area, which can include the groin.
Choice C rationale

Pallor in the affected extremity is not a typical symptom of DVT. DVT can cause swelling and warmth in the affected area, but it does not typically cause pallor.
Choice D rationale
Cramping pain in one foot is not a typical symptom of DVT. DVT often causes pain or swelling in the affected leg, but the pain is not typically limited to the foot.

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A nurse is attending to a client who has just been admitted due to an acute exacerbation of ulcerative colitis. What should be the nurse’s initial course of action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse doesn’t hear any gurgling while listening to bowel sounds. What should be the nurse’s next course of action?

Correct Answer is D

Explanation

A nurse is evaluating a client who is at risk for deep-vein thrombosis (DVT). Which of the following symptoms is an indication of DVT?

Correct Answer is B

Explanation

A nurse is providing discharge teaching for a client who has chronic pancreatitis. Which of the following statements should the nurse make?

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