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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Advancing the catheter 2.5-5 cm after urine flow is incorrect, as this risks advancing too far, potentially injuring the bladder or urethra. The catheter should be inserted until urine flows, then slightly further to ensure bladder placement.
Choice B reason: Contracting pelvic muscles during catheterization is not advised, as it may increase resistance or cause discomfort. Patients should relax to facilitate smooth catheter insertion and minimize trauma to the urethra.
Choice C reason: Inflating a balloon is specific to indwelling (Foley) catheters, not intermittent ones, which lack balloons. This instruction is irrelevant and could confuse the patient, as intermittent catheters are removed after bladder emptying.
Choice D reason: Lubricating the catheter tip with water or water-soluble lubricant reduces friction, easing insertion and minimizing urethral trauma. This is a critical step in self-catheterization to ensure safety and comfort, making it an essential instruction.
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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