ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 48 Questions
Question 1 of 5
A client who is scheduled for an ileostomy surgery and been taking corticosteroids is instructed to taper the drug, eventually discontinuing it. The nurse would monitor this client for which of the following?
Correct Answer: D
Rationale: Adrenal crisis is potentially life-threatening and may result from the abrupt withdrawal of corticosteroids.
Therefore, the nurse should closely monitor a client who is scheduled for an ileostomy surgery for adrenal insufficiency, resulting from corticosteroid withdrawal. Withdrawal of corticosteroids does not cause cerebral anoxia, cardiac dysrhythmias, or hypothyroidism.
Question 2 of 5
Which intervention would be most appropriate for a client who has undergone colostomy surgery?
Correct Answer: C
Rationale: The nurse should monitor the volume of suctioned gastric secretions in a client who has undergone colostomy surgery. The nurse should monitor vital signs once every 4 hours and take temperature by any route other than rectal. The nurse should also ensure that the client's fluid intake is adequate and not minimized.
Question 3 of 5
A nurse is preparing to administer the prescribed vitamin B12 to a client who has had most of his ileum removed. The nurse understands that this is necessary for which reason?
Correct Answer: B
Rationale: Parenteral injections or intranasal administrations of vitamin B12 are used to prevent deficiencies in clients who have had most or all of the ileum removed because this area is responsible for B12 absorption. Vitamin B12 does not prevent thrombosis or constipation or aid digestion.
Question 4 of 5
The nurse is caring for a client who has undergone colostomy. Which of the following instructions should the nurse include in the teaching plan?
Correct Answer: D
Rationale: The nurse should instruct a client who has undergone colostomy to chew food properly. This helps decrease gas that results chiefly from swallowing air rather than from digestion. The client need not limit or avoid travel or outdoor activities. If traveling by air, the nurse should instruct the client to take ostomy supplies in carry-on luggage to prevent their loss if luggage is misdirected or lost. If the client requires firm, light support, he or she should find a stoma shield to help prevent irritation or undue pressure on the stoma.
Question 5 of 5
A client has had surgery to create an ileoanal reservoir. Which instruction would the nurse give to reduce the risk for bowel incontinence?
Correct Answer: C
Rationale:
To reduce the risk for bowel incontinence, the nurse should instruct a client who has undergone ileoanal reservoir surgery to perform perineal exercises. The client need not avoid high-protein food, take walks, or perform warm water soaks because these do not minimize the risk of bowel incontinence.