The nurse has been assigned to provide care for four clients on the day shift. Aher hearing the 1500 hand-off report, which client does the nurse prioritize to see first?

A client admitted with pancreatitis who is requesting pain medication

A client post a liver biopsy who has tachycardia and is restless

A client admitted with ulcerative Colts who is requesting an anti-diarrhea

A client postop day with dark red drainage the size of a dime on the dressing

Answer and Explanation

The Correct Answer is B

A. A client admitted with pancreatitis who is requesting pain medication: While pancreatitis causes severe pain, this is not the highest priority. Pain management is important, but it does not indicate an immediate life-threatening issue.

B. A client post a liver biopsy who has tachycardia and is restless: Tachycardia and restlessness following a liver biopsy may indicate internal bleeding due to liver puncture. The liver is highly vascular, and hemorrhage is a serious complication requiring immediate assessment.

C. A client admitted with ulcerative colitis who is requesting an anti-diarrheal: While diarrhea is distressing, this is not life-threatening. The client can be seen after addressing the higher-priority client.

D. A client postop day 1 with dark red drainage the size of a dime on the dressing: Small amounts of dark red drainage are expected postoperatively. This client does not require immediate attention.

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Correct Answer is D

Explanation

A. "The ileostomy is temporary and can be reversed after 3-4 months.": A total colectomy with ileostomy is typically permanent unless the client is undergoing a two-stage procedure to create a J-pouch.

B. "This procedure will slow down the number of diarrhea stools you pass per rectum.": A total colectomy removes the colon, so stool will no longer pass per rectum. Instead, stool is collected in an external ileostomy bag.

C. "Stool produced by the ileostomy will be firm and require manual removal to drain.": Stool from an ileostomy is liquid to semi-formed due to the lack of water absorption. It does not require manual removal.

D. "This procedure is curative as it removes the part of the bowel affected by the disease.": Ulcerative colitis only affects the colon and rectum. A total colectomy removes the diseased portion, effectively curing the condition.

A. Both require frequent surgery B. Both are inflammatory C. Both begin in the rectum D. Both manifest fistula formation

Correct Answer is B

Explanation

A. Both require frequent surgery: While surgery may be required for complications of UC or CD, not all cases require frequent surgery. UC is more likely to be treated with total colectomy, while Crohn’s often requires surgery for strictures, fistulas, or bowel obstruction.

B. Both are inflammatory: Both ulcerative colitis (UC) and Crohn’s disease (CD) are types of inflammatory bowel disease (IBD) characterized by chronic inflammation of the gastrointestinal tract.

C. Both begin in the rectum: Ulcerative colitis starts in the rectum and progresses proximally, while Crohn’s disease can occur anywhere along the gastrointestinal tract (mouth to anus) but most commonly affects the ileum and colon.

D. Both manifest fistula formation: Fistulas (abnormal connections between organs) are common in Crohn’s disease but not in ulcerative colitis.

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The nurse has been assigned to provide care for four clients on the day shift. Aher hearing the 1500 hand-off report, which client does the nurse prioritize to see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is completing preoperative teaching on a client. Which of the following response should the nurse offer to a client who asks why he's having a total colectomy with ileostomy formation to treat his ulcerative colitis?

Correct Answer is D

Explanation

A nurse is caring for a client who has ulcerative colitis and is teaching the client about the common link with Crohn's disease. Which of the following information should the nurse include?

Correct Answer is B

Explanation

The nurse is providing education to a client with a history of Crohn's Disease and a new diagnosis of anemia. Which of the following statements by the client would require farther teaching?

The nurse is caring for a client with acute pancreatitis. Which of the following would the nurse anticipate seeing in the client's history?

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A nurse is planning care for a client who has end-stage cirrhosis of the liver with hepatic encephalopathy. Which of the following interventions should the nurse plan to implement to decrease the client's ammonia level?

A client who has been caring for an ostomy on the left side of the abdomen for several years is admitted to the hospital. Which type of stool can the nurse expect?