A nurse is caring for a client who was admitted with nausea, vomiting, and a possible bowel obstruction. An NG tube is placed and set to low intermittent suction. Which of the following findings should the nurse report to the provider?

The amount of drainage is gradually decreasing.

The client's abdomen becomes distended and firm.

The client reports being extremely thirsty with a sore throat.

The drainage is bright green in color with brown fecal material.

Answer and Explanation

The Correct Answer is B

Abdominal distension and firmness indicate increased intra-abdominal pressure, which can compromise blood flow to the bowel and cause ischemia, necrosis, or perforation.

The nurse should report this finding to the provider and assess for signs of shock or peritonitis.

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Correct Answer is C

Explanation

An ileostomy is a surgical opening in the abdomen that connects the end of the small intestine (ileum) to a pouch or bag on the outside of the body. The ileostomy bypasses the large intestine (colon) and rectum, which normally absorb water and form solid stools. Therefore, the client should expect their stools to be loose and watery. The client should empty their bag several times a day, not when it is full, to prevent leakage and skin irritation. The client should avoid laxatives, which can cause dehydration and electrolyte imbalance. The client should also avoid high-fiber foods, which can cause blockage or irritation of the ileostomy.

A. Place the client in a protective environment. B. Clean surfaces with chlorhexidine. C. Wash hands with alcohol-based hand rub. D. Obtain a stool specimen with gloves.

Correct Answer is A

Explanation

Clostridium difficile is a spore-forming bacteria that can cause severe diarrhea and other gastrointestinal symptoms. It's highly contagious and can easily spread to other patients.Alcohol-based hand rubs are not effective against spores and should not be used for hand hygiene in this case. Chlorhexidine is also not sporicidal and should not be used for environmental cleaning. A protective environment is indicated for clients who are at risk of infection from others, not for clients who are infectious to others.Gloves are important for preventing the spread of infection, but they should be used in conjunction with other infection control measures, such as handwashing and protective isolation.

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A nurse is caring for a client who was admitted with nausea, vomiting, and a possible bowel obstruction. An NG tube is placed and set to low intermittent suction. Which of the following findings should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to a client who has an ileostomy. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse is planning care for a client who has Clostridium difficile gastroenteritis. Which of the following is an appropriate nursing action?

Correct Answer is A

Explanation

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