A nurse is caring for a client who is being admitted for an acute exacerbation of ulcerative colitis. Which of the following actions should the nurse take first?
Investigate the client's emotional concerns.
Check the client's perianal skin integrity.
Obtain a dietary history from the client.
Review the client's electrolyte values.
The Correct Answer is D
A. Investigate the client's emotional concerns:
While addressing emotional concerns is important, assessing electrolyte imbalances and physiological stability takes precedence in managing an acute exacerbation of ulcerative colitis.
B. Check the client's perianal skin integrity:
Assessing perianal skin integrity is crucial, especially in inflammatory bowel disease, but it might not be the immediate priority compared to evaluating electrolyte imbalances.
C. Obtain a dietary history from the client:
Although dietary history is relevant for managing ulcerative colitis, the urgency lies in assessing and managing potential electrolyte imbalances due to the exacerbation of the condition.
D. Review the client's electrolyte values:
This is the correct action. During an acute exacerbation of ulcerative colitis, the client is at risk of electrolyte imbalances due to diarrhea, dehydration, and potential fluid and electrolyte losses. Promptly reviewing the electrolyte values helps identify any imbalances that might require immediate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Level of consciousness:
While assessing the client's level of consciousness is important, it is not the top priority after an EGD procedure unless there are specific signs of neurological distress. Monitoring for signs of sedation or anesthesia recovery is typically part of post-procedure care.
B. Gag reflex:
This is the correct answer. The nurse should prioritize assessing the gag reflex, as the procedure involves passing a flexible tube through the mouth and down the esophagus. Ensuring the return of the gag reflex is essential to prevent aspiration and ensure the client's safety.
C. Pain:
Pain assessment is important, but it is usually addressed after confirming airway protection and ensuring the absence of complications such as bleeding or perforation.
D. Nausea:
While nausea is a possible post-procedure symptom, assessing the gag reflex and monitoring for signs of complications take precedence over managing nausea in the immediate post-procedure period.
Correct Answer is C
Explanation
A. Instruct the client that they can lift over 20 lbs:
Lifting heavy objects should be avoided postoperatively to prevent strain on the surgical site. The specific weight restriction may vary, but lifting heavy objects is generally discouraged.
B. Offer the client ice cream postoperatively:
While offering ice cream may be a comforting measure, it is not a specific action related to the recovery from a laparoscopic cholecystectomy.
C. Encourage ambulation once fully awake:
This is the correct action. Encouraging ambulation helps prevent complications such as blood clots and promotes recovery after laparoscopic surgery. Early mobility is generally encouraged unless contraindicated for specific reasons.
D. Place the client in a supine position postoperatively:
The position of the client postoperatively depends on the specific surgical procedure and the surgeon's preferences. However, placing the client in a supine position alone is not a comprehensive postoperative care action.
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