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 C
Explanation
A. The charge nurse should follow the staff closely and tell them every single thing they could possibly be doing wrong:
Micromanaging and focusing solely on the negatives can create a stressful and demoralizing work environment. This approach is less likely to motivate and inspire staff.
B. Make the staff aware that all errors will be severely punished:
A punitive approach to errors can create a culture of fear and may not foster a supportive environment for learning and improvement. It can lead to decreased morale and job satisfaction.
C. Acknowledge staff accomplishments when warranted and provide positive feedback:
This is the most effective approach. Recognizing and acknowledging staff achievements, providing positive feedback, and celebrating successes contribute to a positive work environment. It motivates staff to continue their efforts and fosters a culture of teamwork and collaboration.
D. Provide negative feedback with all errors:
While constructive feedback is essential for learning and improvement, a balance between constructive criticism and positive reinforcement is crucial. Constant negative feedback without recognition of positive efforts can lead to decreased morale.
Correct Answer is C
Explanation
A. Clean the peristomal skin four times a day:
While keeping the peristomal skin clean is essential, cleaning it four times a day might be excessive and could lead to skin irritation. Typically, cleansing the area when changing the pouch or as needed is sufficient.
B. Hold pressure on the skin barrier for 10 to 15 seconds to secure the seal:
Applying gentle pressure upon application can assist in securing the seal, but the duration might vary based on the manufacturer's recommendations. It's important not to overly press or manipulate the barrier excessively, as it could cause skin trauma.
C. Empty the pouch when it is 1/3 full:
This is the correct advice. Regularly emptying the pouch prevents leakage and ensures the pouch does not become too heavy or cause skin irritation from weight or pressure.
D. Expect firm fecal content:
With an ileostomy, the fecal content tends to be more liquid compared to other types of ostomies like colostomies, so expecting firm fecal content might not be accurate for this situation.
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