A nurse is planning care for a client who is postoperative and at risk for paralytic ileus.
Which of the following interventions should the nurse plan to take to promote peristalsis?

Decrease fluid intake.

Offer the client the bedpan every 2 hr.

Increase protein intake.

Increase ambulation.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Decreasing fluid intake can lead to dehydration and constipation, which would further impede peristalsis rather than promote it. Adequate hydration is essential for maintaining bowel regularity and facilitating the movement of intestinal contents.

Choice B rationale

Offering the bedpan every 2 hours does not directly stimulate peristalsis. While it provides an opportunity for bowel elimination, it does not address the underlying issue of decreased intestinal motility associated with paralytic ileus.

Choice C rationale

Increasing protein intake does not directly promote peristalsis. While protein is important for overall healing, it does not have a significant impact on stimulating bowel motility. Fiber intake is more directly related to promoting bowel function.

Choice D rationale

Increased ambulation stimulates peristalsis by promoting intestinal motility. Physical activity helps to move gas and fluids through the intestines, reducing the risk of paralytic ileus, which is a functional obstruction of the bowel often occurring after surgery.

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Correct Answer is C

Explanation

Choice A rationale

Checking blood glucose levels for hypoglycemia once yearly is insufficient for a patient taking high doses of oral glucocorticoids for an extended period. Glucocorticoids can cause hyperglycemia by increasing gluconeogenesis and insulin resistance. Therefore, blood glucose monitoring should be more frequent, especially when initiating or adjusting the dosage. Normal fasting blood glucose levels are typically 70-99 mg/dL.

Choice B rationale

Limiting the intake of calcium-rich foods is incorrect advice for a patient on long-term glucocorticoid therapy. Glucocorticoids can decrease calcium absorption from the gut and increase bone resorption, leading to osteoporosis. Therefore, patients on these medications should be encouraged to maintain an adequate intake of calcium and vitamin D to help preserve bone density. Normal total serum calcium levels range from 8.6 to 10.2 mg/dL.

Choice C rationale

Monitoring for fractures over the next several months is an important instruction for a patient taking high doses of oral glucocorticoids long-term. Glucocorticoids increase the risk of osteoporosis and subsequent fractures, particularly vertebral compression fractures and hip fractures, due to their effects on bone metabolism. Regular monitoring and preventive measures are crucial.

Choice D rationale

Glucocorticoids do not boost immunity; instead, they suppress the immune system by inhibiting the production and function of various immune cells and inflammatory mediators. This immunosuppressive effect is why they are used to treat autoimmune diseases like rheumatoid arthritis, but it also increases the risk of infections.

A. Basal cell carcinoma. B. Malignant melanoma. C. Actinic keratosis. D. Squamous cell carcinoma.

Correct Answer is A

Explanation

Choice A rationale

Basal cell carcinoma is the most common type of skin cancer and often presents as a raised, flesh-colored or pearly white lesion with rolled borders and sometimes visible blood vessels (telangiectasia). Its slow growth and characteristic appearance align with the description provided.

Choice B rationale

Malignant melanoma is a more aggressive form of skin cancer that typically appears as an asymmetrical mole with irregular borders, uneven color (often shades of black, brown, red, white, or blue), and a diameter greater than 6 mm. It is less likely to present as a raised, flesh-colored lesion with pearly borders.

Choice C rationale

Actinic keratosis is a precancerous skin condition characterized by rough, scaly patches that develop on sun-exposed areas. These lesions are typically flat or slightly raised and can be red, tan, or flesh-colored. The description of pearly white borders does not typically fit actinic keratosis.

Choice D rationale

Squamous cell carcinoma is the second most common type of skin cancer and can appear as a firm, red nodule or a flat lesion with a scaly or crusted surface. While it can vary in appearance, the description of pearly white borders is more characteristic of basal cell carcinoma.

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A nurse is planning care for a client who is postoperative and at risk for paralytic ileus.Which of the following interventions should the nurse plan to take to promote peristalsis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a patient about taking high doses of oral glucocorticoids for an extended period to treat rheumatoid arthritis.Which of the following instructions should the nurse include in the teaching?

Correct Answer is C

Explanation

During a routine physical examination, a nurse observes a 1-cm (0.4-in) lesion on a client's chest.The lesion is raised and flesh-colored with pearly white borders.The nurse should recognize that this finding is suggestive of which of the following types of skin cancer?

Correct Answer is A

Explanation

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A nurse is planning care for a client who is postoperative and at risk for paralytic ileus.
Which of the following interventions should the nurse plan to take to promote peristalsis?