the client with a colostomy has an order for irrigation of the colostomy the nurse used which solution for irrigation

ATI RN

ATI Gastrointestinal System Quizlet

1. The client with a colostomy has an order for irrigation of the colostomy. The nurse used which solution for irrigation?

A. Distilled water
B. Tap water
C. Sterile water
D. Lactated Ringer’s

Correct answer: B

Rationale: Tap water at body temperature is generally used for colostomy irrigation unless the local water supply is not safe for drinking, in which case bottled water can be used.

2. A 30-year-old woman is admitted to the hospital with complaints of severe abdominal cramping and diarrhea. The nurse evaluates the effectiveness of the patient's intravenous therapy. Which of the following laboratory tests BEST reflects hydration status?

A. Erythrocyte sedimentation rate.
B. White blood cell count.
C. Hematocrit.
D. Serum glucose.

Correct answer: C

Rationale: Hematocrit is the best indicator of hydration status because it reflects the proportion of red blood cells in the blood. An increased hematocrit indicates dehydration, as the blood becomes more concentrated due to fluid loss. Erythrocyte sedimentation rate (Choice A) is a nonspecific marker of inflammation, not hydration status. White blood cell count (Choice B) is an indicator of infection or inflammation. Serum glucose (Choice D) is used to monitor blood sugar levels, not hydration status.

3. The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis. The client is scheduled for surgery for 2 hours. The client begins to complain of increases abdominal pain and begins to vomit. On assessment the nurse notes that the abdomen distended and bowel sounds are diminished. Which of the following is the most appropriate nursing intervention?

A. Administer the prescribed pain medication.
B. Notify the physician.
C. Call and ask the operating room team to perform the surgery as soon as possible.
D. Reposition the client and apply a heating pad on warm setting to the client’s abdomen.

Correct answer: B

Rationale: Based on the signs and symptoms presented in the question, the nurse should suspect peritonitis and should notify the physician. Administering pain medication is not an appropriate intervention. Heat should never be applied to the abdomen of a client with suspected appendicitis. Scheduling surgical time is not within the scope of nursing practice, although the physician probably would perform the surgery earlier than the prescheduled time.

4. You’re discharging Nathaniel with hepatitis B. Which statement suggests understanding by the patient?

A. Now I can never get hepatitis again.
B. I can safely give blood after 3 months.
C. I’ll never have a problem with my liver again, even if I drink alcohol.
D. My family knows that if I get tired and start vomiting, I may be getting sick again.

Correct answer: D

Rationale: Understanding that family needs to be aware of symptoms that may indicate a recurrence of hepatitis B shows proper understanding by the patient.