Performance
Exit
Physiological Adaptation Mastery -
Proficient
Due Oct 23, 2022 by 8:59 pm
Passed
148 out of 148 questions answered correctly
Completed on Sep 23, 2022 11:16 pm
Incorrect (0)
Correct (148)
A client with ulcerative colitis has experienced frequent severe
exacerbations over the past several years. The client is admitted to
,the hospital with intense pain, severe diarrhea, and cachexia. Which
therapeutic course would the nurse expect the primary health care
provider to explore with this client?
Intensive psychotherapy
Continued medical therapy
Surgical therapy (colectomy)
Diet therapy (low-residue, high-protein diet)
Rationale
If medical management fails, surgical therapy is the next logical choice because it
removes the affected intestine. Psychotherapy might improve the client's ability to
cope with the disease, but it will not solve the physical problems. Continued
medical therapy and diet therapy are classic interventions that probably have been
tried during prior exacerbations and have failed.
For which clinical indicators would the nurse monitor when caring
for a client with cholelithiasis and obstructive jaundice? Select all
that apply. One, some, or all responses may be correct.
Dark urine
Yellow skin
Pain on urination
Clay-colored stool
Coffee-ground vomitus
,Rationale
When bile levels in the bloodstream are high, as in obstructive jaundice, there is
bile in the urine, causing it to have a dark color. Jaundice (bile pigments causing
yellow skin, sclera, and mucous membranes) results from failure of bile to enter
the intestines, with subsequent backup into the biliary system and diffusion into
the blood; the bilirubin is carried to all body regions. The stools are clay-colored,
not brown, because the bile pigments are not present in the gastrointestinal (GI)
tract as a result of the obstruction of the common bile duct. Pain is experienced in
the right upper quadrant, not on urination, because of spasm of the gallbladder,
whether or not there is biliary obstruction. Coffee-ground vomitus indicates
gastric bleeding; it is not a unique sign of cholelithiasis with obstructive jaundice.
The nurse providing immediate postoperative care to a client who
had an abdominoperineal resection would assess for which clinical
indicator of complications?
Blood in the nasogastric tube
Return of bowel sounds
Absence of output from the stoma
Bloody drainage on the abdominal and rectal dressings
Rationale
Bloody drainage on the abdominal or rectal dressings may indicate hemorrhage.
Blood in the NG tube is expected immediately after surgery. Peristalsis will not
return for several days. The colostomy will not function until peristalsis returns.
Immediately after a subtotal gastrectomy, a client is admitted to the
postanesthesia care unit (PACU). The nurse irrigates the nasogastric
tube and observes small blood clots in the return. Which action
would the nurse take?
, would the nurse take?
Clamp the nasogastric tube.
Irrigate the tube with iced saline.
Document this expected response.
Notify the health care provider of this finding.
Rationale
As a result of the trauma of surgery, some bleeding is expected for several hours.
Clamping the tube will cause increased pressure on the gastric sutures from a
buildup of gas and fluid. Iced saline is used rarely because it causes
vasoconstriction, local ischemia, and a reduction in body temperature. Notifying
the health care provider of this finding is not necessary; bleeding during the
immediate postoperative period is an expected occurrence.
Which finding would the nurse expect when assessing a client
diagnosed with hypovolemic shock?
Oliguria
Crackles
Dyspnea
Bounding pulse
Rationale
Urine output decreases to less than 20 to 30 mL/hr (oliguria) because of decreased
renal perfusion secondary to a decreased circulating blood volume. Crackles are
associated with pulmonary edema caused by cardiogenic shock, not hypovolemic
shock. Dyspnea may be associated with hypervolemia, not hypovolemia, and also
Exit
Physiological Adaptation Mastery -
Proficient
Due Oct 23, 2022 by 8:59 pm
Passed
148 out of 148 questions answered correctly
Completed on Sep 23, 2022 11:16 pm
Incorrect (0)
Correct (148)
A client with ulcerative colitis has experienced frequent severe
exacerbations over the past several years. The client is admitted to
,the hospital with intense pain, severe diarrhea, and cachexia. Which
therapeutic course would the nurse expect the primary health care
provider to explore with this client?
Intensive psychotherapy
Continued medical therapy
Surgical therapy (colectomy)
Diet therapy (low-residue, high-protein diet)
Rationale
If medical management fails, surgical therapy is the next logical choice because it
removes the affected intestine. Psychotherapy might improve the client's ability to
cope with the disease, but it will not solve the physical problems. Continued
medical therapy and diet therapy are classic interventions that probably have been
tried during prior exacerbations and have failed.
For which clinical indicators would the nurse monitor when caring
for a client with cholelithiasis and obstructive jaundice? Select all
that apply. One, some, or all responses may be correct.
Dark urine
Yellow skin
Pain on urination
Clay-colored stool
Coffee-ground vomitus
,Rationale
When bile levels in the bloodstream are high, as in obstructive jaundice, there is
bile in the urine, causing it to have a dark color. Jaundice (bile pigments causing
yellow skin, sclera, and mucous membranes) results from failure of bile to enter
the intestines, with subsequent backup into the biliary system and diffusion into
the blood; the bilirubin is carried to all body regions. The stools are clay-colored,
not brown, because the bile pigments are not present in the gastrointestinal (GI)
tract as a result of the obstruction of the common bile duct. Pain is experienced in
the right upper quadrant, not on urination, because of spasm of the gallbladder,
whether or not there is biliary obstruction. Coffee-ground vomitus indicates
gastric bleeding; it is not a unique sign of cholelithiasis with obstructive jaundice.
The nurse providing immediate postoperative care to a client who
had an abdominoperineal resection would assess for which clinical
indicator of complications?
Blood in the nasogastric tube
Return of bowel sounds
Absence of output from the stoma
Bloody drainage on the abdominal and rectal dressings
Rationale
Bloody drainage on the abdominal or rectal dressings may indicate hemorrhage.
Blood in the NG tube is expected immediately after surgery. Peristalsis will not
return for several days. The colostomy will not function until peristalsis returns.
Immediately after a subtotal gastrectomy, a client is admitted to the
postanesthesia care unit (PACU). The nurse irrigates the nasogastric
tube and observes small blood clots in the return. Which action
would the nurse take?
, would the nurse take?
Clamp the nasogastric tube.
Irrigate the tube with iced saline.
Document this expected response.
Notify the health care provider of this finding.
Rationale
As a result of the trauma of surgery, some bleeding is expected for several hours.
Clamping the tube will cause increased pressure on the gastric sutures from a
buildup of gas and fluid. Iced saline is used rarely because it causes
vasoconstriction, local ischemia, and a reduction in body temperature. Notifying
the health care provider of this finding is not necessary; bleeding during the
immediate postoperative period is an expected occurrence.
Which finding would the nurse expect when assessing a client
diagnosed with hypovolemic shock?
Oliguria
Crackles
Dyspnea
Bounding pulse
Rationale
Urine output decreases to less than 20 to 30 mL/hr (oliguria) because of decreased
renal perfusion secondary to a decreased circulating blood volume. Crackles are
associated with pulmonary edema caused by cardiogenic shock, not hypovolemic
shock. Dyspnea may be associated with hypervolemia, not hypovolemia, and also
