A nurse is creating a plan of care to maintain the skin integrity of a client who experiences frequent diarrhea due to ulcerative colitis. Which of the following interventions should the nurse include in the plan?

Administer a soap-suds enema to cleanse the colon.

Soak in a sitz bath for 20 min after each stool.

Wipe perianal area with warm water and apply a barrier cream.

Cleanse with antimicrobial scrub and vigorously dry.

Answer and Explanation

The Correct Answer is C

A. Soap-suds enemas are not recommended for clients with ulcerative colitis because they can irritate the colon and worsen symptoms. Enemas should be used cautiously, if at all, and only when medically indicated.
B. Soaking in a sitz bath can help soothe perianal discomfort, but it is not the most effective intervention for protecting the skin from diarrhea-related irritation. Barrier creams are a more direct way to protect the skin from further damage.
C. Wiping the perianal area with warm water and applying a barrier cream is an appropriate and effective intervention to protect the skin. The warm water is gentle, and the barrier cream provides a protective layer that helps prevent skin breakdown from frequent contact with stool.
D. Cleansing with an antimicrobial scrub and vigorously drying the perianal area could cause further irritation and damage to already sensitive skin. The focus should be on gentle cleansing and protecting the skin with a barrier cream.

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Correct Answer is D

Explanation

A. Chronic alcohol consumption can contribute to ulcers but is not the primary cause of duodenal ulcers. It can increase stomach acid and irritate the mucosal lining.
B. High intake of spicy foods is often blamed for ulcers, but it is not a direct cause. Spicy foods may exacerbate symptoms but do not cause ulcers.
C. Inadequate fiber intake is not a significant factor in the development of duodenal ulcers. Diet can influence overall digestive health but is not the main cause.
D. Nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin and ibuprofen, are a leading cause of duodenal ulcers. They inhibit prostaglandin production, which protects the mucosal lining of the stomach and duodenum, leading to ulcer formation and increased risk of bleeding.

A. Position head of bed at 10 degrees. B. Encourage fluid intake of 1500 mL/day. C. Cough and deep breathe every 8 hr. D. Obtain a sputum culture.

Correct Answer is D

Explanation

A. Positioning the head of the bed at 10 degrees is not sufficient for optimizing respiratory function. Typically, the head of the bed should be elevated to 30–45 degrees to help with breathing and reduce the risk of aspiration.
B. Encouraging fluid intake of 1500 mL/day may be too low for a client with pneumonia. Adequate hydration is important to thin mucus and help with expectoration, especially in the context of pneumonia. Typically, fluid intake should be higher unless contraindicated.
C. Coughing and deep breathing every 8 hours is insufficient. To prevent atelectasis and promote effective clearance of secretions in clients with pneumonia, coughing and deep breathing should be done more frequently, typically every 2 hours.
D. Obtaining a sputum culture is a priority for determining the specific pathogen causing the pneumonia and guiding antibiotic treatment. A sputum culture helps identify bacterial, viral, or fungal organisms that may be present, which is crucial for managing recurrent pneumonia, especially in an immunocompromised client with AIDS.

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A nurse is creating a plan of care to maintain the skin integrity of a client who experiences frequent diarrhea due to ulcerative colitis. Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 36-year-old patient with suspected gastrointestinal (GI) bleeding undergoes a diagnostic endoscopy which determines the site of bleeding is a duodenal ulcer. The nurse explains to the patient that bleeding ulcers are commonly related to which of the following:

Correct Answer is D

Explanation

A nurse is implementing a plan of care for a client who has AIDS with recurring pneumonia. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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