A nurse is caring for a client.
Nurses' Notes 0900:
Client reports a 3-month history of intermittent diarrhea and abdominal pain. Reports unintentional weight loss of 5.5 kg (12 lb) in 3 months.
0930:
Stool sample obtained for fecal occult blood test. Fatty appearance and foul odor noted.
For each assessment 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.
Weight loss
Steatorrhea
Anemia
Diarrhea
Fever
The Correct Answer is {"A":{"answers":"A,C"},"B":{"answers":"C"},"C":{"answers":"A,C"},"D":{"answers":"A,C"},"E":{"answers":"C"}}
A. Weight loss - Consistent with: Ulcerative colitis, Crohn's disease
B. Steatorrhea - Consistent with: Crohn's disease
C. Anemia - Consistent with: Ulcerative colitis, Crohn's disease
D. Diarrhea - Consistent with: Ulcerative colitis, Crohn's disease
E. Fever - Consistent with: Crohn's disease
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Incorrect. Urination is not directly related to the evaluation of the effectiveness of a paracentesis procedure.
B. Incorrect. Checking serum albumin levels may be important in managing ascites, but it is not a direct measure of the immediate effectiveness of the paracentesis.
C. Correct. Monitoring the client's weight is a common way to assess the effectiveness of a paracentesis, as the procedure aims to remove excess abdominal fluid (ascites), which can lead to a reduction in body weight.
D. Incorrect. Examining for leakage at the site of the procedure is important for safety but does not directly reflect the effectiveness of the paracentesis.
Correct Answer is D
Explanation
As explained, holding the bottle directly over the sterile field can result in contamination. It's crucial to pour the solution from above or to the side of the sterile field, making sure the bottle doesn't touch the field or anything in the field. This minimizes the risk of contaminating the sterile setup.
If solution is spilled on the sterile field, that area is contaminated, and you cannot make it sterile again by covering it with gauze. The correct approach would be to discard the contaminated items and set up a new sterile field.
While it's important not to touch the label side of the bottle, this option doesn't address the action of placing the cap. The most important part of pouring a sterile solution is ensuring the cap stays sterile, which is what option D addresses.
When performing a sterile procedure, after removing the cap from a sterile bottle, the cap should be placed sterile-side up on a clean surface or a sterile field. This is because the sterile side of the cap should not touch any non-sterile surfaces, and placing it sterile-side up ensures it stays sterile.
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