Your patient, Christopher, has a diagnosis of ulcerative colitis and has severe abdominal pain aggravated by movement, rebound tenderness, fever, nausea, and decreased urine output. This may indicate which complication?

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Bowel perforation. Christopher's presentation with severe abdominal pain aggravated by movement, rebound tenderness, fever, nausea, and decreased urine output is concerning for a bowel perforation. A bowel perforation is a serious complication of ulcerative colitis where there is a hole in the wall of the intestine. This leads to leakage of bowel contents into the abdominal cavity, causing severe pain, tenderness, fever, and signs of peritonitis like rebound tenderness. The decreased urine output may indicate hypovolemia due to fluid shifting into the peritoneal cavity. Option A) Fistula is incorrect as fistulas are abnormal connections between organs or vessels, not indicative of a bowel perforation in this context. Option C) Bowel obstruction typically presents with different signs and symptoms such as abdominal distension, constipation, and vomiting, which are not prominent in this case. Option D) Abscess would present with localized pain, swelling, and possibly a palpable mass, which are not described in Christopher's case. Educationally, understanding the complications of ulcerative colitis is crucial for nurses to provide timely and appropriate interventions to prevent further deterioration in patients like Christopher. Recognizing the signs and symptoms of bowel perforation can help nurses advocate for prompt medical attention and potentially life-saving interventions.

Correct Answer: A

Rationale: In the context of a patient with liver failure, limiting meats and beans (Option A) in the diet is crucial due to their high protein content. The liver is responsible for metabolizing proteins, and in liver failure, the organ's ability to process protein is compromised, leading to ammonia buildup and potential encephalopathy. By reducing protein intake, the workload on the liver is decreased, helping to manage symptoms and prevent further damage. Butter and gravies (Option B) are high in fats, which can worsen liver function as the liver struggles to process them. Excessive fat consumption can lead to fatty liver disease and exacerbate the patient's condition. Potatoes and pastas (Option C) are sources of carbohydrates and are generally acceptable in moderation for a patient with liver failure unless they have other comorbid conditions like diabetes or obesity. Carbohydrates provide energy and are not as directly taxing on the liver as proteins and fats. Cakes and pastries (Option D) are high in sugars and unhealthy fats, which can contribute to weight gain and fatty liver disease. These should be limited in a patient with liver failure to prevent further stress on the liver. Educationally, understanding dietary restrictions in liver failure is essential for patient care. Teaching families about appropriate food choices helps them support the patient's health and recovery. It also highlights the importance of individualized care based on the patient's specific condition to optimize outcomes.

Correct Answer: B

Rationale: The correct response, B) Stop the feeding, and clamp the NG tube, is based on the principle of patient safety and preventing complications. Aspirating 220ml of gastric residual suggests poor gastric emptying and potential risk for aspiration, which can lead to respiratory compromise. By stopping the feeding and clamping the NG tube, you are preventing the patient from receiving more feedings that could potentially exacerbate the situation. Option A) Notify the doctor immediately is not the first response because immediate action is needed to address the risk of aspiration. Waiting for a physician's response could delay necessary interventions. Option C) Discard the 220ml, and clamp the NG tube is incorrect because discarding the aspirate without taking action to prevent further feeding could still lead to complications. Option D) Give a prescribed GI stimulant such as metoclopramide (Reglan) is not appropriate in this situation as the priority is to address the immediate risk of aspiration rather than promoting gastric motility. In an educational context, understanding the significance of gastric residuals in enteral feedings is crucial for nurses caring for patients with NG tubes. Prompt recognition of abnormal findings and appropriate actions can prevent serious complications and promote patient safety in medical-surgical settings.

Correct Answer: D

Rationale: Delegating tasks such as providing skin care, maintaining intake and output records, and obtaining the client's weight are within the scope of practice for an unlicensed assistant. Assessing bowel sounds and evaluating the response to medications require nursing judgment and should not be delegated.

Correct Answer: B

Rationale: In the context of caring for a client with ulcerative colitis experiencing symptoms, the correct answer is B) Providing skin care following bowel movements. This task can be appropriately delegated to an unlicensed assistant as it involves maintaining the client's hygiene and preventing skin breakdown, which aligns with their scope of practice and does not require specialized nursing assessment or medical decision-making. Option A, assessing the client's bowel sounds, involves a higher level of assessment that requires nursing judgment and skill, so it should not be delegated to an unlicensed assistant. Option C, evaluating the client's response to antidiarrheal medications, involves monitoring for potential side effects and effectiveness of the medication, which requires nursing assessment and critical thinking. Option D, administration of pain medication every 4 hours, involves medication administration, which is a nursing responsibility due to the need for accurate dosage calculation, understanding of potential side effects, and monitoring the client's response. Educationally, understanding delegation in nursing is crucial for ensuring safe and effective patient care. Nurses must be able to differentiate tasks that can be delegated to unlicensed personnel from those that require nursing expertise to provide appropriate care and uphold patient safety. This rationale highlights the importance of delegation principles and the significance of knowing each team member's scope of practice to optimize patient outcomes.