2| Already Rated A| Rasmussen College
❖ The client who has ulcerative colitis is scheduled for an ileostomy. When the client asks
the nurse what to expect related to bowel function and care after surgery, what response
should the nurse make?
- "The stoma will require that you wear a collection device"
❖ A male patient suffered a brain injury from a motor vehicle accident and has no brain
activity. The spouse has come up to see the patient every day for the past 2 months. She
asks the nurse, "Do you think when he moves his hands he is responding to my voice?"
The nurse feels bad because she believes the movements are involuntary, and the
prognosis is grim for this patient. She states, "He can hear you, and it appears he did
respond to your voice." The nurse is violating which principle of ethics?
- Veracity
❖ A client is prescribed trimethoprim-sulfamethoxazole (Bactrim) for a urinary tract
infection. Which of the following instructions would not be appropriate for this
medication?
- Take with an antacid
❖ The nursing instructor is discussing the focused physical assessment for bowel
elimination with a student nurse. Which statement by the student nurse indicates a need
for additional teaching?
, - "listening to bowel sounds and looking at the abdomen's contour are parts
of this focused assessment.
❖ Twenty minutes after a client has received a preoperative injection of atropine and
midazolam (Versed), the client tells the nurse that he must be allergic to the medication
because his mouth is dry and his heart seems to be beating faster than normal. What is
the nurse's priority action?
- Assess the client's pulse and blood pressure
❖ Which of the following is a primary prevention tool used for colon cancer screening?
- Occult blood testing
❖ A client is hospitalized with urinary retention, has an indwelling catheter, and is getting
IV fluids. Which intervention does the nurse add to the care plan to address the priority
problem for this client?
- Perform indwelling urinary catheter care.
❖ The nurse is obtaining an elimination history from the client. Which of the following
questions address the client's normal bowel elimination pattern? (SATA)
- "What time of the day do you usually have a bowel movement?"
- "How often do you move your bowels?"
- "Tell me about any routines you have for moving your bowels."