A client with a history of inflammatory bowel disease develops severe ulcerative colitis and is admitted to the intensive care unit after surgery for a fistula repair.
Which intervention is most important for the nurse to include in the plan of care?

Turn every 2 hours around the clock from side-to-side.

Assess skin condition and turgor for breakdown.

Record the amount of daily wound drainage.

Replace fluids IV based on intake and output.

Answer and Explanation

The Correct Answer is D

Choice D rationale

In a patient with severe ulcerative colitis who has undergone surgery for a fistula repair, replacing fluids IV based on intake and output is the most important intervention to include in the plan of care. This is because patients with ulcerative colitis often experience significant fluid and electrolyte imbalances due to diarrhea and other gastrointestinal losses. Following surgery, these imbalances can be further exacerbated by factors such as fasting, surgical stress, and the use of certain medications. Therefore, careful monitoring of fluid and electrolyte balance, and appropriate IV fluid replacement, is crucial to prevent complications such as dehydration, electrolyte imbalances, and renal dysfunction.

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Correct Answer is A

Explanation

Choice A rationale

Exenatide is a medication used to improve blood sugar control in adults with type 2 diabetes. One of the potential side effects of exenatide is pancreatitis, which can cause severe abdominal pain. Therefore, patients should be instructed to notify their healthcare provider if they start having abdominal pain after starting exenatide.

Choice B rationale

Exenatide should be injected within 60 minutes (1 hour) before the morning and evening meal (or before the two main meals of the day, at least 6 hours apart), not 30 minutes before or after a meal. Therefore, this instruction is incorrect.

Choice C rationale

Exenatide does not act in the same way as insulin. While both insulin and exenatide help to control high blood sugar, they work in different ways. Insulin allows sugar in your blood to enter your cells, while exenatide works by increasing the release of insulin when blood sugar levels are high, decreasing the amount of glucose produced and released by the liver, and slowing gastric emptying.

Choice D rationale

There are precautions about taking exenatide with other medications. For example, exenatide may affect the absorption of some orally administered drugs due to its effect on gastric emptying. Therefore, patients should be advised to take oral medications that require rapid absorption at least 1 hour before injecting exenatide.

A. Assist the spouse and carefully give the patient small sips of water. B. Obtain thickening powder before providing any more fluids. C. Ask the spouse to stop and assess the patient’s swallowing reflex. D. Give the spouse a straw to help facilitate the patient’s drinking.

Correct Answer is C

Explanation

Choice A rationale

Assisting the spouse and carefully giving the patient small sips of water may seem like a compassionate action. However, it could potentially lead to aspiration if the patient’s swallowing reflex is compromised, which is common in stroke patients.

Choice B rationale

While obtaining thickening powder before providing any more fluids can help prevent aspiration in patients with dysphagia, it is not the immediate action the nurse should take. The nurse first needs to assess the patient’s swallowing reflex before deciding on the appropriate intervention.

Choice C rationale

The nurse should ask the spouse to stop and assess the patient’s swallowing reflex. This is the most immediate and appropriate action. Stroke patients often have impaired swallowing reflexes, which can lead to aspiration if not properly managed. By assessing the swallowing reflex, the nurse can determine the best course of action to ensure the patient’s safety.

Choice D rationale

Giving the spouse a straw to help facilitate the patient’s drinking is not the best course of action. Straws can increase the risk of aspiration in patients with impaired swallowing reflexes. The nurse should first assess the patient’s swallowing reflex before deciding on the appropriate intervention.

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A client with a history of inflammatory bowel disease develops severe ulcerative colitis and is admitted to the intensive care unit after surgery for a fistula repair.Which intervention is most important for the nurse to include in the plan of care?

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Explanation

Correct Answer is C

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A client with a history of inflammatory bowel disease develops severe ulcerative colitis and is admitted to the intensive care unit after surgery for a fistula repair.
Which intervention is most important for the nurse to include in the plan of care?