Assessment findings for a client following a colectomy for familial polyposis include an ileostomy bag that contains a large amount of fecal liquid and an IV infusion of dextrose 5% in lactated Ringer's infusing at a rate of 100 mL/hour. Which assessment is most
Urinary output.
Serum electrolytes.
Peristomal skin integrity.
Skin turgor.
The Correct Answer is B
A. While monitoring urinary output is important, it is not the most critical assessment in this context.
B. Monitoring serum electrolytes is crucial because the large amount of fecal liquid output from the ileostomy can lead to significant electrolyte imbalances.
C. Peristomal skin integrity is important but is secondary to the immediate risk of electrolyte imbalances.
D. Skin turgor is important for assessing hydration status, but monitoring electrolytes is more directly related to the immediate postoperative care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A: Dairy products such as milk, yogurt, and cheese are rich sources of calcium, which is essential for bone health and can help prevent osteoporosis, especially in older adults.
B: While fruits and vegetables are important for overall health, they do not provide significant amounts of calcium, which is the primary nutrient needed for preventing osteoporosis.
C: Iron-rich meals are important for preventing anemia but do not directly contribute to bone health and prevention of osteoporosis.
D: While hydration is important for overall health, water and herbal teas do not provide significant amounts of calcium needed for bone health.
Correct Answer is B
Explanation
A. While it's important for the nurse to explain the need for education, the client's belief in personal benefits is more motivating.
B. The belief that their needs will be met through education fosters motivation.
C. Empathy from the nurse can enhance the learning experience but might not solely motivate the client.
D. Seeking family approval is an external motivator, but personal belief in the benefits of education is more intrinsic.
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