The nurse identifies a client problem of impaired skin integrity related to diarrhea for a client who has ulcerative colitis. The nurse recognizes that teaching about perianal care has been effective when the client:

cleans and dries the perianal area after each diarrheal stool.

uses alcohol compresses to provide relief from anal irritation.

asks for antidiarrheal medication after each stool.

takes an hour-long Sitz bath following each stool.

Answer and Explanation

The Correct Answer is A

A.   Cleans and dries the perianal area after each diarrheal stool: This is the correct option. Effective perianal care for a client with diarrhea, such as ulcerative colitis, involves gentle cleansing and thorough drying of the perianal area after each stool. Proper hygiene helps prevent skin breakdown and irritation caused by prolonged contact with stool.
B.   Alcohol can be irritating to the skin and may exacerbate perianal irritation and discomfort. Therefore, using alcohol compresses is not considered an appropriate perianal care practice.
C.   While antidiarrheal medications may be prescribed for clients with ulcerative colitis to help manage symptoms, asking for medication after each stool is not a typical or recommended approach. The frequency and timing of antidiarrheal medication administration should be based on healthcare provider recommendations and individual symptom management plans.
D.   While Sitz baths can provide relief from perianal discomfort and promote healing, taking an hour-long Sitz bath after each stool may be impractical and excessive. Sitz baths are typically recommended for shorter durations (e.g., 10-20 minutes) and may be used periodically rather than after every stool.

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Correct Answer is A

Explanation

A. Hemoglobin 7.8: This finding indicates a low hemoglobin level, which suggests significant blood loss, likely due to the actively bleeding peptic ulcer. Hemoglobin levels below normal can indicate anemia, and a level of 7.8 is particularly concerning. This finding should be immediately reported to the physician because it suggests ongoing bleeding and the need for intervention to stabilize the client's hemoglobin levels and prevent further complications such as hypovolemic shock.
B. Blood pressure = 118/78: This blood pressure reading falls within the normal range for most adults. While monitoring blood pressure is important, this finding alone may not be immediately concerning in the context of a bleeding peptic ulcer.
C. The presence of occult blood in the stool suggests gastrointestinal bleeding, which is consistent with the actively bleeding peptic ulcer. While this finding is significant, it may not require immediate reporting to the physician as it is expected in the context of the client's condition.
D. Epigastric pain is a common symptom of peptic ulcer disease, and worsening pain on palpation may indicate peritonitis or perforation, which are serious complications of peptic ulcers. However, if the pain is severe or associated with signs of peritonitis it should be promptly reported to the physician for further evaluation and management.

A. Change the IV site dressing every 48-72 hours B. Change the IV tubing every 24 hours C. Weigh the client every other day on the same scale D. Obtain the client's blood glucose every 12 hours

Correct Answer is B

Explanation

B. Changing the IV tubing every 24 hours helps prevent the accumulation of bacteria and other contaminants within the tubing, reducing the risk of infection. This practice is particularly important for clients receiving TPN, as they are at higher risk of infection due to the direct infusion of nutrients into the bloodstream.
A. It is essential to maintain the integrity of the IV site to prevent infection and ensure proper TPN delivery. Changing the IV site dressing every 24 hours helps minimize the risk of contamination and infection at the insertion site.
C. Regular monitoring of the client's weight is not necessary.
D. While monitoring blood glucose levels is important for clients at risk of hyperglycemia or hypoglycemia, the frequency of monitoring should be individualized based on the client's clinical condition and risk factors.

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The nurse identifies a client problem of impaired skin integrity related to diarrhea for a client who has ulcerative colitis. The nurse recognizes that teaching about perianal care has been effective when the client:

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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