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 A

Explanation

A. The IV tubing for TPN should be changed every 24 hours to prevent infection, as TPN is a high-risk solution for bacterial growth due to its high glucose content. Regular changes help reduce the risk of contamination and complications such as bloodstream infections.
B. The IV site dressing should be changed at least every 48 to 72 hours (or per institutional policy) to maintain aseptic technique and minimize infection risk. Changing the dressing every 4 days may exceed this timeframe and increase the risk of infection.
C. Weighing the client is important to monitor fluid balance, but daily weighing is more typical than every other day for clients receiving TPN. This helps to assess nutritional status and detect potential fluid overload or deficit.
D. Blood glucose levels should be monitored more frequently, typically every 6 hours, because TPN can cause significant fluctuations in blood glucose. Checking every 12 hours would not be adequate for early detection of hyperglycemia or hypoglycemia.

A. Notifying the healthcare provider if they are experiencing a moon phase. B. Taking the steroid medication as prescribed. C. Notifying the healthcare provider if the blood glucose level is over 150 mg/dL. D. Taking this medication on an empty stomach.

Correct Answer is B

Explanation

A. "Moon phase" is not a correct term related to prednisone use. The term "moon face" refers to the round, puffy face that can result from prolonged steroid use, which is a side effect, but it is not something the patient needs to notify the healthcare provider about unless it is accompanied by other severe symptoms.
B. Taking the steroid medication as prescribed is essential. Prednisone is a corticosteroid, and missing doses or abruptly stopping the medication can lead to complications such as adrenal insufficiency. It's important for the client to adhere to the prescribed regimen to manage inflammation and minimize the risk of side effects.
C. Steroids like prednisone can cause increased blood glucose levels, so it's important for the client to monitor blood glucose more frequently. If blood glucose levels exceed 150 mg/dL, they should notify their healthcare provider, but this is not the immediate management strategy for this scenario.
D. Prednisone should be taken with food to reduce gastrointestinal irritation, not on an empty stomach. Taking it without food can increase the risk of stomach upset and ulcers, particularly in patients with inflammatory bowel disease.

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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 nurse is assessing a client who is receiving total parenteral nutrition (TPN) therapy via an infusion pump. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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