A nurse is planning care for a client admitted with diarrhea. Which of the following interventions would be a priority for this client?

Monitor for fluid and electrolyte disturbances

Use standard precautions when caring for the client

Identify cause of diarrhea and assess bowel habits

Encourage client to eat small frequent meals

Answer and Explanation

The Correct Answer is A

Choice A reason: Diarrhea causes significant fluid and electrolyte losses, particularly sodium, potassium, and bicarbonate, risking dehydration and acid-base imbalances. Monitoring these parameters is critical to prevent hypovolemia, arrhythmias, or metabolic acidosis, making it the priority intervention for patient stability.

Choice B reason: Standard precautions are necessary to prevent infection transmission but are a routine practice, not the priority. While important for safety, they do not address the immediate physiological threat of fluid and electrolyte imbalances caused by ongoing diarrhea.

Choice C reason: Identifying the cause of diarrhea and assessing bowel habits is important for long-term management but is secondary to stabilizing the patient. Fluid and electrolyte losses pose an immediate risk, requiring urgent monitoring before diagnostic or historical assessments.

Choice D reason: Encouraging small, frequent meals may help manage diarrhea long-term by reducing gastrointestinal irritation, but it is not the priority. Addressing fluid and electrolyte imbalances takes precedence to prevent life-threatening complications like dehydration or hypokalemia.

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Correct Answer is ["A","C","E"]

Explanation

Choice A reason: Reassessing the pain score is critical to evaluate the medication’s effectiveness. Pain is subjective, and reassessment using a numerical scale (e.g., 0-10) quantifies relief, guiding further dosing or alternative interventions. This ensures adequate pain control, optimizing patient comfort and recovery.

Choice B reason: Assessing the surgical site is important for monitoring complications like infection or bleeding but is not directly related to pain medication administration. Pain relief does not typically alter surgical site appearance, making this assessment less immediate compared to pain or systemic effects of analgesics.

Choice C reason: Reassessing vital signs is essential as pain medications, especially opioids, can cause respiratory depression, hypotension, or bradycardia. Monitoring heart rate, blood pressure, and respiratory rate ensures patient safety, detecting adverse effects early to prevent complications like hypoxia or cardiovascular instability.

Choice D reason: Assessing bowel sounds is relevant for long-term opioid use due to risks of constipation, but it’s not an immediate post-administration priority. Pain medications’ acute effects primarily involve pain relief and systemic responses, not gastrointestinal motility, making this less critical in the immediate post-dose period.

Choice E reason: Assessing level of consciousness is crucial as pain medications, particularly opioids, can cause sedation or altered mental status. Monitoring alertness ensures patient safety, detecting overdose or adverse reactions early, which could lead to respiratory depression or other life-threatening complications if unaddressed.

A. A risk factor is high intake of animal fats or red meat. B. A warning sign is rectal bleeding. C. A risk factor is smoking. D. A warning sign is diarrhea.

Correct Answer is D

Explanation

Choice A reason: High intake of animal fats or red meat is a recognized risk factor for colorectal cancer. These foods, high in saturated fats, may promote inflammation and alter gut microbiota, increasing carcinogenesis risk in the colon, supported by epidemiological studies linking diet to cancer.

Choice B reason: Rectal bleeding is a warning sign of colorectal cancer. It results from tumor erosion or ulceration in the colon or rectum, causing blood in stool. This symptom prompts diagnostic evaluation, like colonoscopy, to detect malignancy early, improving treatment outcomes.

Choice C reason: Smoking is a risk factor for colorectal cancer. Tobacco’s carcinogenic compounds, like polycyclic aromatic hydrocarbons, damage colonic mucosa, increasing mutation risk. Smoking also promotes inflammation, contributing to tumor development, making it a significant modifiable risk factor in colorectal cancer prevention.

Choice D reason: Diarrhea is not a specific warning sign of colorectal cancer. While it may occur, it’s more commonly associated with infections or irritable bowel syndrome. Cancer typically presents with persistent bleeding, weight loss, or bowel habit changes, making diarrhea less diagnostic and misleading for teaching.

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A nurse is planning care for a client admitted with diarrhea. Which of the following interventions would be a priority for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","C","E"]

Explanation

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Correct Answer is D

Explanation

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