ATI LPN
Test Bank for Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care 10th Edition
Chapter 57 : Care of Patients with Inflammatory Intestinal Disorders Questions
Question 1 of 5
A nurse assesses a client who has ulcerative colitis and severe diarrhea. Which assessment should the nurse complete first?
Correct Answer: C
Rationale: Severe diarrhea can lead to hypovolemia and electrolyte imbalances, such as low potassium or magnesium, which may cause dysrhythmias. Assessing heart rate and rhythm is the priority to detect potential cardiac complications. Oral mucosa inspection, dietary intake review, and abdominal percussion are important but lower priority.
Question 2 of 5
A nurse assesses a client with Crohn's disease and colonic strictures. Which clinical manifestation should alert the nurse to urgently contact the health care provider?
Correct Answer: A
Rationale: Colonic strictures predispose the client to intestinal obstruction. A distended abdomen may indicate an obstruction, requiring urgent notification of the provider. Low-grade fever, loose and bloody stools, and abdominal cramps are common symptoms of Crohn's disease and do not require immediate intervention.
Question 3 of 5
A nurse reviews the chart of a client who has Crohn's disease and a draining fistula. Which documentation should alert the nurse to urgently contact the provider for additional prescriptions?
Correct Answer: A
Rationale: A serum potassium level of 2.6 mEq/L is critically low and can lead to serious dysrhythmias, requiring urgent intervention. A normal white blood cell count (8200/mm³) does not warrant immediate action. Reduced meal intake and weight loss are concerning but less urgent than hypokalemia.
Question 4 of 5
After teaching a client who has a new colostomy, the nurse provides feedback based on the client's ability to complete self-care activities. Which statement should the nurse include in this feedback?
Correct Answer: B
Rationale: Feedback should be objective and constructive, acknowledging what was done well (clearing the stoma) and identifying areas for improvement (applying the appliance). General reassurance, vague inquiries, or suggesting someone else manage the ostomy are not constructive.
Question 5 of 5
A nurse assesses a client who is hospitalized for diverticulitis. The client's vital signs are temperature: 99.8°F (37.6°C), heart rate: 100 beats/min, respiratory rate: 18 breaths/min, and blood pressure: 100/62 mm Hg. Which action should the nurse take first?
Correct Answer: B
Rationale: The client's vital signs suggest possible hypovolemia or early sepsis due to diverticulitis (elevated heart rate, low blood pressure, and mild fever). Staying with the client and having another nurse contact the provider ensures rapid assessment and intervention. Rest, fluid rate increase, or glucose checks are not the priority without further assessment.