The nurse is creating a home care checklist for a patient diagnosed with inflammatory bowel disease (IBD) who is being discharged. The patient had an ostomy from a previous surgery. What interventions will the nurse include in this plan?
Perform weekly occult blood testing with gastric analysis test.
Discuss nutritional management with inclusion of a high-protein, high-vitamin diet.
Leave ostomy site open to air for an hour each day when changing the appliance.
Instruct the patient and family how to give medications through their G-tube.
The Correct Answer is B
Choice A reason: Performing weekly occult blood testing with gastric analysis is not typically required for managing IBD at home. While monitoring for blood in the stool can be important, weekly testing and gastric analysis are more invasive and usually performed under specific medical instructions rather than as a routine home care intervention.
Choice B reason: Discussing nutritional management with the inclusion of a high-protein, high-vitamin diet is crucial for patients with IBD. These patients often experience malnutrition due to poor absorption and increased nutritional needs during flare-ups. A high-protein, high-vitamin diet can help promote healing, maintain muscle mass, and prevent deficiencies. This intervention supports overall health and recovery.
Choice C reason: Leaving the ostomy site open to air for an hour each day when changing the appliance is not recommended. Ostomy sites need to be kept clean and protected to prevent infection and skin irritation. Instead, the focus should be on proper cleaning and secure application of the ostomy appliance.
Choice D reason: Instructing the patient and family on how to give medications through their G-tube is not relevant if the patient has an ostomy. A G-tube is used for feeding and medication administration in patients with impaired oral intake, which is not indicated in this scenario. The focus should be on ostomy care and management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Scattered petechiae on bilateral lower extremities are a common finding in patients with thrombocytopenia, indicating low platelet count and increased risk of bleeding. While this finding is concerning, it is not as immediate a threat as significant bleeding or bruising.
Choice B reason: Ecchymosis around the intravenous site suggests significant bleeding and bruising, which can be more urgent and requires immediate reporting. A platelet count of 10,000/mm³ is critically low, increasing the risk of spontaneous bleeding and haemorrhage. Immediate intervention is necessary to prevent further complications.
Correct Answer is D
Explanation
Choice A reason: Fever is not a common side effect of albuterol. It may indicate an infection or another underlying condition that should be evaluated separately.
Choice B reason: Bruising is not associated with albuterol use. Bruising may be related to other medications or underlying conditions affecting coagulation.
Choice C reason: Polyuria, or increased urination, is not a typical side effect of albuterol. It is more commonly associated with conditions such as diabetes or diuretic use.
Choice D reason: Palpitations are a known side effect of albuterol due to its stimulating effect on the heart. Patients should be informed about this potential side effect and advised to report any persistent or severe palpitations to their healthcare provider.
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