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 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.
Question 2 of 5
A nurse cares for a client who has a Giardia infection. Which medication should the nurse anticipate being prescribed for this client?
Correct Answer: A
Rationale: Metronidazole is the drug of choice for Giardia, a parasitic infection. Ciprofloxacin and ceftriaxone treat bacterial infections, and sulfasalazine is used for ulcerative colitis or Crohn's disease, not Giardia.
Question 3 of 5
A nurse cares for a client who has food poisoning resulting from a Clostridium botulinum infection. Which assessment should the nurse complete first?
Correct Answer: D
Rationale: Clostridium botulinum infection can cause respiratory failure due to neurotoxin effects. Assessing respiratory rate and oxygen saturation is the priority to detect early signs of respiratory compromise. Other assessments are important but secondary.
Question 4 of 5
A nurse plans care for a client with Crohn's disease who has a heavily draining fistula. Which intervention should the nurse indicate as the priority action in this client's plan of care?
Correct Answer: B
Rationale: A heavily draining fistula releases caustic intestinal fluids that can cause skin breakdown or infections. Skin protection is the priority to prevent complications. Nutrition, antibiotics, and glucose monitoring are important but secondary.
Question 5 of 5
A nurse assesses a client who is recovering from an ileostomy placement. Which clinical manifestation should alert the nurse to urgently contact the health care provider?
Correct Answer: A
Rationale: A pale or bluish stoma indicates potential ischemia or poor perfusion, requiring urgent provider notification. Liquid stool and blood-smeared output are expected after ileostomy placement, and an intact pouch is normal.