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 ["B","E","H"]

Explanation

Choice A rationale

While albuterol can cause an increase in heart rate due to its beta-agonist effects, it is not the primary assessment following administration. The main goal of albuterol treatment is to improve respiratory function.

Choice B rationale

Breath sounds are a primary assessment following albuterol administration. Albuterol is a bronchodilator and should improve breath sounds by reducing bronchospasm and increasing airflow.

Choice C rationale

Serum sodium levels are not directly affected by albuterol and therefore are not a primary assessment following its administration.

Choice D rationale

A complete blood count is not directly affected by albuterol and therefore is not a primary assessment following its administration.

Choice E rationale

Oxygen saturation is a primary assessment following albuterol administration. Albuterol should improve oxygen saturation by increasing airflow and oxygen delivery.

Choice F rationale

Peak inspiratory flow is not typically assessed after albuterol administration. Albuterol primarily affects expiratory flow by reducing bronchospasm.

Choice G rationale

Temperature is not directly affected by albuterol and therefore is not a primary assessment following its administration.

Choice H rationale

Peak expiratory flow is a primary assessment following albuterol administration. Albuterol is a bronchodilator and should improve peak expiratory flow by reducing bronchospasm.

A. Ask the patient how often episodes of sundowning are experienced. B. Inquire about the frequency of falls in recent months. C. Request the patient to lie as still as possible for the assessment. D. Assist the patient with clarifying values about end-of-life care options.

Correct Answer is B

Explanation

Choice A rationale

Asking the patient how often episodes of sundowning are experienced is more relevant in assessing cognitive function, particularly in patients with dementia. It is not directly related to the patient’s weight loss or decreased energy and appetite.

Choice B rationale

Inquiring about the frequency of falls in recent months is crucial in a functional assessment of an older patient who has lost weight and reports a decrease in energy and appetite. Weight loss and decreased energy can increase the risk of falls, which can lead to serious injuries and further functional decline.

Choice C rationale

Requesting the patient to lie as still as possible for the assessment is not directly related to the patient’s weight loss or decreased energy and appetite. It might be necessary for certain physical examinations or procedures, but it is not the most relevant action in this context.

Choice D rationale

Assisting the patient with clarifying values about end-of-life care options is an important aspect of geriatric care, especially in patients with serious illnesses. However, it is not directly related to the patient’s weight loss or decreased energy and appetite.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After administering the prescribed albuterol nebulizer treatment, what should the nurse assess?

Correct Answer is ["B","E","H"]

Explanation

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Correct Answer is B

Explanation

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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?