A nurse is creating a plan of care to maintain the skin integrity of a client who experiences frequent diarrhea due to ulcerative colitis. Which of the following interventions should the nurse include in the plan?

Administer a soap-suds enema to cleanse the colon.

Soak in a sitz bath for 20 min after each stool.

Wipe perianal area with warm water and apply a barrier cream.

Cleanse with antimicrobial scrub and vigorously dry.

Answer and Explanation

The Correct Answer is C

A. Soap-suds enemas are not recommended for clients with ulcerative colitis because they can irritate the colon and worsen symptoms. Enemas should be used cautiously, if at all, and only when medically indicated.
B. Soaking in a sitz bath can help soothe perianal discomfort, but it is not the most effective intervention for protecting the skin from diarrhea-related irritation. Barrier creams are a more direct way to protect the skin from further damage.
C. Wiping the perianal area with warm water and applying a barrier cream is an appropriate and effective intervention to protect the skin. The warm water is gentle, and the barrier cream provides a protective layer that helps prevent skin breakdown from frequent contact with stool.
D. Cleansing with an antimicrobial scrub and vigorously drying the perianal area could cause further irritation and damage to already sensitive skin. The focus should be on gentle cleansing and protecting the skin with a barrier cream.

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Correct Answer is D

Explanation

A. Inflammation of the esophagus (esophagitis) may cause symptoms like heartburn or dysphagia, but it would not explain the sudden, sharp pain or rigid abdomen seen with a perforated ulcer.
B. An intestinal obstruction can cause abdominal pain and distension, but the rigid, board-like abdomen is more characteristic of peritonitis from a perforated ulcer, not an obstruction.
C. Additional ulcers could cause pain and bleeding, but they would not explain the sudden, sharp pain and rigid abdomen that typically result from perforation.
D. The sudden onset of sharp, severe pain in the mid epigastric area, along with a rigid, board-like abdomen, are hallmark signs of a perforated ulcer, which causes peritonitis. This is a medical emergency, as the perforation allows gastric contents to leak into the peritoneal cavity, leading to widespread infection.

A. The patient's white blood cell (WBC) count is 6000/μL. B. Bronchial breath sounds are heard at the right base. C. Increased tactile fremitus is palpable over the right chest. D. The patient coughs up small amounts of green mucus.

Correct Answer is A

Explanation

A. A decrease in the white blood cell count toward normal levels indicates that the infection is responding to antibiotic treatment. A WBC count of 6000/μL is within the normal range for adults (usually 4,000–11,000/μL), which suggests that the body is no longer fighting a significant infection.
B. Bronchial breath sounds heard at the right base indicate consolidation, a sign of ongoing pneumonia or unresolved infection. This would suggest that the infection is not yet controlled, rather than an improvement.
C. Increased tactile fremitus indicates consolidation, which is commonly seen in pneumonia. It suggests that the infection is still present and has not resolved with treatment.
D. Green mucus can indicate the presence of purulent sputum and ongoing infection. Although the color of the mucus may change during the course of pneumonia, the presence of green mucus does not confirm that the infection is resolving, especially after three days of antibiotics.

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A nurse is creating a plan of care to maintain the skin integrity of a client who experiences frequent diarrhea due to ulcerative colitis. Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A patient with right lower-lobe pneumonia has been treated with IV antibiotics for 3 days. Which assessment data obtained by the nurse indicates that the treatment is effective?

Correct Answer is A

Explanation

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