A client admitted with acute diverticulitis has experienced a sudden increase in temperature and reports a sudden onset of extreme abdominal tenderness. The nurse's rapid assessment reveals that the client's abdomen is uncharacteristically rigid on palpation. What is the nurse's best response?
Call the primary provider and report that the client may be obstructed.
Position the client supine and insert an NG tube.
Administer a fleet enema as prescribed and remain with the client.
Contact the primary provider promptly and report these signs of perforation.
The Correct Answer is D
Choice A reason: This is not the best response because it does not accurately describe the client's condition. Obstruction is a possible complication of diverticulitis, but it is not indicated by fever and abdominal rigidity. Obstruction is more likely to cause symptoms such as nausea, vomiting, constipation, and abdominal distension.
Choice B reason: This is not the best response because it can worsen the client's condition. Positioning the client supine and inserting an NG tube are interventions for gastric outlet obstruction, not diverticulitis. An NG tube can increase the risk of infection and perforation in the inflamed colon. Supine position can also increase the pressure on the abdomen and cause more pain and discomfort.
Choice C reason: This is not the best response because it can be harmful to the client. Administering a fleet enema is contraindicated for diverticulitis, as it can cause more inflammation, bleeding, or perforation in the colon. A fleet enema is a type of laxative that contains sodium phosphate and is used to relieve constipation or prepare for colonoscopy.
Choice D reason: This is the best response because it is the most appropriate and urgent action for the client. Contacting the primary provider promptly and reporting these signs of perforation is essential for the client's safety and treatment. Perforation is a life-threatening complication of diverticulitis, where the colon wall ruptures and causes peritonitis, which is inflammation of the abdominal cavity. Perforation can cause symptoms such as fever, abdominal rigidity, tenderness, and rebound pain. Perforation requires immediate surgical intervention and antibiotic therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A reason: Oily stools are common, especially when excessive fat is consumed, because orlistat blocks the absorption of fat in the intestines. The undigested fat is then eliminated in the stool, making it oily, greasy, or foul-smelling.
Choice B reason: Many patients note having an increase of gas and flatus, because orlistat can also interfere with the digestion of carbohydrates and proteins, causing fermentation and gas production in the colon.
Choice C reason: Constipation is not a common side effect with this medication. In fact, orlistat may cause the opposite effect of diarrhea, as the unabsorbed fat can irritate the bowel and increase the motility.
Choice D reason: Some patients report the development of fecal incontinence, because orlistat can cause unpredictable bowel movements and difficulty in controlling the passage of stool, especially if the patient consumes a high-fat diet.
Choice E reason: This medication does have side effects, even though it can be bought over the counter. Orlistat is a prescription-strength drug that can cause serious adverse reactions, such as liver damage, kidney stones, gallbladder problems, and vitamin deficiencies. The over-the-counter version is a lower dose than the prescription one, but it still requires medical supervision and lifestyle changes.
Correct Answer is A
Explanation
Choice A reason: Monitoring respiratory status for signs and symptoms of pulmonary complications is a priority nursing intervention for a client with hypervolemia. Hypervolemia is a condition where there is excess fluid in the blood vessels, which can cause fluid to leak into the lungs and impair gas exchange. The nurse should assess the client for signs of pulmonary edema, such as dyspnea, crackles, cough, and pink-tinged sputum.
Choice B reason: Encouraging the client to consume sodium-free fluids is not a priority nursing intervention for a client with hypervolemia. Sodium-free fluids may still contribute to fluid overload, especially if the client has impaired renal function or heart failure. The nurse should limit the client's fluid intake and administer diuretics as prescribed to reduce the fluid volume.
Choice C reason: Weighing dressings with a large-bore catheter is not a priority nursing intervention for a client with hypervolemia. This may be a relevant intervention for a client with hemorrhage, who may lose blood through a large-bore catheter or dressing. The nurse should monitor the client's blood pressure, pulse, and hemoglobin levels for signs of blood loss.
Choice D reason: Drawing a blood sample for typing and cross-matching is not a priority nursing intervention for a client with hypervolemia. This may be a relevant intervention for a client who needs a blood transfusion, which may be indicated for a client with anemia, trauma, or surgery. The nurse should check the client's blood type and compatibility before administering any blood products.
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