Nursing Test Banks Chapter 47: Bowel Elimination Potter et al.: Fundamentals of Nursing, 9th Edition ,100% CORRECT

Document Content and Description Below

Nursing Test Banks Chapter 47: Bowel Elimination Potter et al.: Fundamentals of Nursing, 9th Edition MULTIPLE CHOICE 1. The nurse is teaching a health class about the gastrointestinal tract. The nurse... will explain that which portion of the digestive tract absorbs most of the nutrients? a. Ileum b. Cecum c. Stomach d. Duodenum ANS: D The duodenum and jejunum absorb most nutrients and electrolytes in the small intestine. The ileum absorbs certain vitamins, iron, and bile salts. Food is broken down in the stomach. The cecum is the beginning of the large intestine. DIF:Understand (comprehension)REF:1150 OBJ: Discuss the role of gastrointestinal organs in digestion and elimination. TOP: Teaching/Learning MSC: Health Promotion and Maintenance 2. The nurse is caring for patients with ostomies. In which ostomy location will the nurse expect very liquid stool to be present? a. Sigmoid b. Transverse c. Ascending d. Descending ANS: C The path of digestion goes from the ascending, across the transverse, to the descending and finally passing into the sigmoid; therefore, the least formed stool (very liquid) would be in the ascending. DIF:Apply (application)REF:1150 OBJ: Explain the physiological aspects of normal defecation. TOP: Assessment MSC: Physiological Adaptation 3. A nurse is teaching a patient about the large intestine in elimination. In which order will the nurse list the structures, starting with the first portion? a. Cecum, ascending, transverse, descending, sigmoid, and rectum b. Ascending, transverse, descending, sigmoid, rectum, and cecum c. Cecum, sigmoid, ascending, transverse, descending, and rectum d. Ascending, transverse, descending, rectum, sigmoid, and cecum ANS: A The large intestine is divided into the cecum, ascending colon, transverse colon, descending colon, sigmoid colon, and rectum. The large intestine is the primary organ of bowel elimination. DIF:Understand (comprehension)REF:1150 OBJ: Discuss the role of gastrointestinal organs in digestion and elimination. TOP: Teaching/Learning MSC: Health Promotion and Maintenance 4. The nurse is planning care for a group of patients. Which task will the nurse assign to the nursing assistive personnel (NAP)? a. Performing the first postoperative pouch change b. Maintaining a nasogastric tube c. Administering an enema d. Digitally removing stool ANS: C The skill of administering an enema can be delegated to an NAP. The skill of inserting and maintaining a naso- gastric (NG) tube cannot be delegated to an NAP. The nurse should do the first postoperative pouch change. Digitally removing stool cannot be delegated to nursing assistive personnel. DIF:Apply (application)REF:1170 OBJ: Use critical thinking in providing care to patients with alterations in bowel elimination. TOP lanningMSC:Management of Care 5. A nurse is assisting a patient in making dietary choices that promote healthy bowel elimination. Which menu option should the nurse recommend? a. Broccoli and cheese soup with potato bread b. Turkey and mashed potatoes with brown gravy c. Grape and walnut chicken salad sandwich on whole wheat bread d. Dinner salad topped with hard-boiled eggs, cheese, and fat-free dressing ANS: C Grapes and whole wheat bread are high fiber and should be chosen. Cheese, eggs, potato bread, and mashed potatoes do not contain as much fiber as whole wheat bread. A healthy diet for the bowel should include foods high in bulk-forming fiber. Whole grains, fresh fruit, and fresh vegetables are excellent sources. Foods without much fiber and with high levels of fat can slow down peristalsis, causing constipation. DIF:Apply (application)REF:1151 | 1168 OBJ:List nursing interventions that promote normal elimination. TOP: Implementation MSC: Health Promotion and Maintenance 6. A patient is using laxatives three times daily to lose weight. After stopping laxative use, the patient has diffi- culty with constipation and wonders if laxatives should be taken again. Which information will the nurse share with the patient? a. Long-term laxative use causes the bowel to become less responsive to stimuli, and constipation may occur. b. Laxatives can cause trauma to the intestinal lining and scarring may result, leading to decreased peristalsis. c. Long-term use of emollient laxatives is effective for treatment of chronic constipation and may be useful in certain situations. d. Laxatives cause the body to become malnourished, so when the patient begins eating again, the body absorbs all of the food, and no waste products are produced. ANS: A Teach patients about the potential harmful effects of overuse of laxatives, such as impaired bowel motility and decreased response to sensory stimulus. Make sure the patient understands that laxatives are not to be used long term for maintenance of bowel function. Increasing fluid and fiber intake can help with this problem. Lax- atives do not cause scarring. Even if malnourished, the body will produce waste if any substance is consumed. DIF:Understand (comprehension)REF:1163 OBJ: Discuss psychological and physiological factors that influence the elimination process. TOP: Teaching/Learning MSC: Health Promotion and Maintenance 7. A patient with a hip fracture is having difficulty defecating into a bedpan while lying in bed. Which action by the nurse will assist the patient in having a successful bowel movement? a. Preparing to administer a barium enema b. Withholding narcotic pain medication c. Administering laxatives to the patient d. Raising the head of the bed ANS: D Lying in bed is an unnatural position; raising the head of the bed assists the patient into a more normal posi- tion that allows proper contraction of muscles for elimination. Laxatives would not give the patient control over bowel movements. A barium enema is a diagnostic test, not an intervention to promote defecation. Pain relief measures should be given; however, preventative action should be taken to prevent constipation. DIF:Apply (application)REF:1151 OBJ: Discuss psychological and physiological factors that influence the elimination process. TOP: Implementation MSC: Basic Care and Comfort 8. Which patient is most at risk for increased peristalsis? a. A 5-year-old child who ignores the urge to defecate owing to embarrassment b. A 21-year-old female with three final examinations on the same day c. A 40-year-old female with major depressive disorder d. An 80-year-old male in an assisted-living environment ANS: B Stress can stimulate digestion and increase peristalsis, resulting in diarrhea; three finals on the same day is stressful. Ignoring the urge to defecate, depression, and age-related changes of the older adult (80-year-old man) are causes of constipation, which is from slowed peristalsis. DIF:Apply (application)REF:1151 OBJ escribe common physiological alterations in elimination. TOP: Assessment MSC: Psychosocial Integrity 9. A patient expresses concerns over having black stool. The fecal occult test is negative. Which response by the nurse is most appropriate? a. “This is probably a false negative; we should rerun the test.” b. “You should schedule a colonoscopy as soon as possible.” c. “Are you under a lot of stress?” d. “Do you take iron supplements?” ANS: D Certain medications and supplements, such as iron, can alter the color of stool (black or tarry). Since the fecal occult test is negative, bleeding is not occurring. The fecal occult test takes three separate samples over a peri- od of time and is a fairly reliable test. A colonoscopy is health prevention screening that should be done every 5 to 10 years; it is not the nurse’s initial priority. Stress alters GI motility and stool consistency, not color. DIF:Analyze (analysis)REF:1156-1157 OBJ: Use critical thinking in providing care to patients with alterations in bowel elimination. TOP: Implementation MSC: Health Promotion and Maintenance 10. Which patient will the nurse assess most closely for an ileus? a. A patient with a fecal impaction b. A patient with chronic cathartic abuse c. A patient with surgery for bowel disease and anesthesia d. A patient with suppression of hydrochloric acid from medication ANS: C Any surgery that involves direct manipulation of the bowel temporarily stops peristalsis. Anesthesia can also cause cessation of peristalsis. This condition, called an ileus, usually lasts about 24 to 48 hours. Fecal im- paction, cathartic abuse, and medication to suppress hydrochloric acid will have bowel sounds, but they may be hypoactive or hyperactive. DIF:Apply (application)REF:1151 OBJ escribe common physiological alterations in elimination. TOP:AssessmentMSC:Management of Care 11. A patient has a fecal impaction. Which portion of the colon will the nurse assess? a. Descending b. Transverse c. Ascending d. Rectum ANS: D A fecal impaction is a collection of hardened feces wedged in the rectum that cannot be expelled. It results from unrelieved constipation. Feces at this point in the colon contain the least amount of moisture. Feces found in the ascending, transverse, and descending colon still consist mostly of liquid and do not form a hard- ened mass. DIF:Apply (application)REF:1152 OBJ: Assess a patient’s elimination pattern. TOP: Assessment MSC: Basic Care and Comfort 12. The nurse is managing bowel training for a patient. To which patient is the nurse most likely providing care? a. A 25-year-old patient with diarrhea b. A 30-year-old patient with Clostridium difficile c. A 40-year-old patient with an ileostomy d. A 70-year-old patient with stool incontinence ANS: D The patient with chronic constipation or fecal incontinence secondary to cognitive impairment may benefit from bowel training, also called habit training. An ileostomy, diarrhea, and C. difficile all relate to uncontrollable bowel movements, for which no method can be used to set up a schedule of elimination. DIF:Analyze (analysis)REF:1168 OBJ: List nursing interventions included in bowel training. TOP: Implementation MSC: Basic Care and Comfort 13. Which nursing intervention is most effective in promoting normal defecation for a patient who has muscle weakness in the legs? a. Administer a soapsuds enema every 2 hours. b. Use a mobility device to place the patient on a bedside commode. c. Give the patient a pillow to brace against the abdomen while bearing down. d. Elevate the head of the bed 20 degrees 60 minutes after breakfast while on bedpan. ANS: B The best way to promote normal defecation is to assist the patient into a posture that is as normal as possible for defecation. Using a mobility device promotes nurse and patient safety. Elevating the head of the bed is ap- propriate but is not the most effective; closer to 30 to 45 degrees is the proper position for the patient on a bedpan, and the patient is not on bed rest so a bedside commode is the best choice. Giving the patient a pillow may reduce discomfort, but this is not the best way to promote defecation. A soapsuds enema is indicated for a patient who needs assistance to stimulate peristalsis. It promotes non-natural defecation. DIF:Apply (application)REF:1151 | 1155 OBJ:List nursing interventions that promote normal elimination. TOP: Implementation MSC: Basic Care and Comfort 14. The nurse is devising a plan of care for a patient with the nursing diagnosis of Constipation related to opioid use. Which outcome will the nurse evaluate as successful for the patient to establish normal defecation? a. The patient reports eliminating a soft, formed stool. b. The patient has quit taking opioid pain medication. c. The patient’s lower left quadrant is tender to the touch. d. The nurse hears bowel sounds in all four quadrants. ANS: A The nurse’s goal is for the patient to take opioid medication and to have normal bowel elimination. Normal stools are soft and formed. Ceasing pain medication is not a desired outcome for the patient. Tenderness in the left lower quadrant indicates constipation and does not indicate success. Bowel sounds indicate that the bowels are moving; however, they are not an indication of defecation. DIF:Apply (application)REF:1150 | 1169 OBJ:List nursing diagnoses related to alterations in elimination. TOP:EvaluationMSC:Management of Care 15. The nurse is emptying an ileostomy pouch for a patient. Which assessment finding will the nurse report im- mediately? a. Liquid consistency of stool b. Presence of blood in the stool c. Malodorous stool d. Continuous output from the stoma ANS: B Blood in the stool indicates a problem, and the health care provider should be notified. All other options are expected findings for an ileostomy. The stool should be liquid, there should be an odor, and the output should be continuous. DIF:Analyze (analysis)REF:1153 | 1157 OBJ: Use critical thinking in providing care to patients with alterations in bowel elimination. TOP:AssessmentMSC:Management of Care 16. The nurse will anticipate which diagnostic examination for a patient with black tarry stools? a. Ultrasound b. Barium enema c. Endoscopy d. Anorectal manometry ANS: C Black tarry stools are an indication of bleeding in the GI tract; endoscopy would allow visualization of the bleed- ing. No other option (ultrasound, barium enema, and anorectal manometry) would allow GI visualization. DIF:Apply (application)REF:1157-1158 OBJ escribe nursing implications for common diagnostic examinations of the gastrointestinal tract.TOP lanningMSC:Management of Care 17. The nurse has attempted to administer a tap water enema for a patient with fecal impaction with no suc- cess. The fecal mass is too large for the patient to pass voluntarily. Which is the next priority nursing action? a. Preparing the patient for a second tap water enema b. Obtaining an order for digital removal of stool c. Positioning the patient on the left side d. Inserting a rectal tube ANS: B When enemas are not successful, digital removal of the stool may be necessary to break up pieces of the stool or to stimulate the anus to defecate. Tap water enemas should not be repeated because of risk of fluid imbal- ance. Positioning the patient on the left side does not promote defecation. A rectal tube is indicated for a pa- tient with liquid stool incontinence or flatus but would not be applicable or effective for this patient. DIF:Apply (application)REF:1152 | 1166 OBJ: Use critical thinking in providing care to patients with alterations in bowel elimination. TOP: Implementation MSC: Basic Care and Comfort 18. A nurse is checking orders. Which order should the nurse question? a. A normal saline enema to be repeated every 4 hours until stool is produced b. A hypertonic solution enema for a patient with fluid volume excess c. A Kayexalate enema for a patient with severe hypokalemia d. An oil retention enema for a patient with constipation ANS: C Kayexalate binds to and helps excrete potassium, so it would be contraindicated in patients who are hy- pokalemic (have low potassium). Normal saline enemas can be repeated without risk of fluid or electrolyte im- balance. Hypertonic solutions are intended for patients who cannot handle large fluid volume and are con- traindicated for dehydrated patients. Oil retention enemas lubricate the feces in the rectum and colon and are used for constipation. DIF:Analyze (analysis)REF:1165 OBJ: Use critical thinking in providing care to patients with alterations in bowel elimination. TOP:ImplementationMSC:Management of Care 19. The nurse is performing a fecal occult blood test. Which action should the nurse take? a. Test the quality control section before testing the stool specimens. b. Apply liberal amounts of stool to the guaiac paper. c. Report a positive finding to the provider. d. Don sterile disposable gloves. ANS: C Abnormal findings such as a positive test (turns blue) should be reported to the provider. A fecal occult blood test is a clean procedure; sterile gloves are not needed. A thin specimen smear is all that is required. The quali- ty control section should be developed after it is determined whether the sample is positive or negative. DIF:Apply (application)REF:1158 OBJ: Describe nursing implications for common diagnostic examinations of the gastrointestinal tract. TOP: Im- plementation MSC: Reduction of Risk Potential 20. A nurse is preparing a patient for a magnetic resonance imaging (MRI) scan. Which nursing action is most important? a. Ensuring that the patient does not eat or drink 2 hours before the examination. b. Administering a colon cleansing product 6 hours before the examination. c. Obtaining an order for a pain medication before the test is performed. d. Removing all of the patient’s metallic jewelry. ANS: D No jewelry or metal products should be in the same room as an MRI machine because of the high-power mag- net used in the machine. The patient needs to be NPO 4 to 6 hours before the examination. Colon cleansing products are not necessary for MRIs. Pain medication is not needed before the examination is performed. DIF:Apply (application)REF:1158 OBJ: Describe nursing implications for common diagnostic examinations of the gastrointestinal tract. TOP: Im- plementation MSC: Reduction of Risk Potential 21. A patient with a fecal impaction has an order to remove stool digitally. In which order will the nurse per- form the steps, starting with the first one? 1. Obtain baseline vital signs. 2. Apply clean gloves and lubricate. 3. Insert index finger into the rectum. 4. Identify patient using two identifiers. 5. Place patient on left side in Sims’ position. 6. Massage around the feces and work down to remove. ANS: A The steps for removing a fecal impaction are as follows: identify patient using two identifiers; obtain baseline vital signs; place on left side in Sims’ position; apply clean gloves and lubricate; insert index finger into the rec- tum; and gently loosen the fecal mass by massaging around it and work the feces downward toward the end of the rectum. DIF:Understand (comprehension)REF:1166 OBJ:List nursing interventions that promote normal elimination. TOP: Implementation MSC: Basic Care and Comfort 22. Before administering a cleansing enema to an 80-year-old patient, the patient says “I don’t think I will be able to hold the enema.” Which is the next priority nursing action? a. Rolling the patient into right-lying Sims’ position b. Positioning the patient in the dorsal recumbent position on a bedpan c. Inserting a rectal plug to contain the enema solution after administering d. Assisting the patient to the bedside commode and administering the enema ANS: B If you suspect the patient of having poor sphincter control, position on bedpan in a comfortable dorsal recum- bent position. Patients with poor sphincter control are unable to retain all of the enema solution. Administering an enema with the patient sitting on the toilet is unsafe because it is impossible to safely guide the tubing into the rectum, and it will be difficult for the patient to retain the fluid as he or she is in the position used for emp- tying the bowel. Rolling the patient into right-lying Sims’ position will not help the patient retain the enema. Use of a rectal plug to contain the solution is inappropriate and unsafe. DIF:Apply (application)REF:1171 OBJ:List nursing interventions that promote normal elimination. TOP:ImplementationMSC:Management of Care 23. A nurse is providing care to a group of patients. Which patient will the nurse see first? a. A child about to receive a normal saline enema b. A teenager about to receive loperamide for diarrhea c. An older patient with glaucoma about to receive an enema d. A middle-aged patient with myocardial infarction about to receive docusate sodium ANS: C An enema is contradicted in a patient with glaucoma; this patient should be seen first. All the rest are expected. A child can receive normal saline enemas since they are isotonic. Loperamide, an antidiarrheal, is given for di- arrhea. Docusate sodium is given to soften stool for patients with myocardial infarction to prevent straining. DIF:Analyze (analysis)REF:1171 OBJ: Use critical thinking in providing care to patients with alterations in bowel elimination. TOP:AssessmentMSC:Management of Care 24. A patient is diagnosed with a bowel obstruction. Which type of tube is the best for the nurse to obtain for gastric decompression? a. Salem sump b. Small bore c. Levin d. 8 Fr ANS: A The Salem sump tube is preferable for stomach decompression. The Salem sump tube has two lumina: one for removal of gastric contents and one to provide an air vent. When the main lumen of the sump tube is connect- ed to suction, the air vent permits free, continuous drainage of secretions. While the Levin tube can be used for decompression, it is only a single-lumen tube with holes near the tip. Large-bore tubes, 12 Fr and above, are usually used for gastric decompression or removal of gastric secretions. Fine- or small-bore tubes are frequent- ly used for medication administration and enteral feedings. DIF:Apply (application)REF:1166 OBJ: Use critical thinking in providing care to patients with alterations in bowel elimination. TOP lanningMSC:Management of Care 25. A patient had an ileostomy surgically placed 2 days ago. Which diet will the nurse recommend to the pa- tient to ease the transition of the new ostomy? a. Eggs over easy, whole wheat toast, and orange juice with pulp b. Chicken fried rice with fresh pineapple and iced tea c. Turkey meatloaf with white rice and apple juice d. Fish sticks with sweet corn and soda ANS: C During the first few days after ostomy placement, the patient should consume easy-to-digest soft foods such as poultry, rice, and noodles. Fried foods can irritate digestion. Foods high in fiber will be useful later in the re- covery process but can cause food blockage if the GI tract is not accustomed to digesting with an ileostomy. Foods with indigestible fiber such as sweet corn, popcorn, raw mushrooms, fresh pineapple, and Chinese cab- bage could cause this problem. DIF:Apply (application)REF:1168 OBJ: Discuss nursing care measures required for patients with a bowel diversion. TOP: Implementation MSC: Physiological Adaptation 26. A nurse is pouching an ostomy on a patient with an ileostomy. Which action by the nurse is most appropriate? a. Changing the skin barrier portion of the ostomy pouch daily b. Emptying the pouch if it is more than one-third to one-half full c. Thoroughly cleansing the skin around the stoma with soap and water to remove excess stool and adhesive d. Measuring the correct size for the barrier device while leaving a 1/2-inch space around the stoma ANS: B Pouches must be emptied when they are one-third to one-half full because the weight of the pouch may dis- rupt the seal of the adhesive on the skin. The barrier device should be changed every 3 to 7 days unless it is leaking or is no longer effective. Peristomal skin should be gently cleansed; vigorous rubbing can cause further irritation or skin breakdown. Avoid soap. It leaves a residue on skin, which may irritate the skin. The pouch opening should fit around the stoma and cover the peristomal skin to prevent contact with the effluent. Excess space, like 1/2 inch, allows fecal matter to have prolonged exposure to skin, resulting in skin breakdown. DIF:Apply (application)REF:1179 OBJ: Discuss nursing care measures required for patients with a bowel diversion. TOP: Implementation MSC: Physiological Adaptation 27. The nurse will irrigate a patient’s nasogastric (NG) tube. Which action should the nurse take? a. Instill solution into pigtail slowly. b. Check placement after instillation of solution. c. Immediately aspirate after instilling fluid. d. Prepare 60 mL of tap water into Asepto syringe. ANS: C After instilling saline, immediately aspirate or pull back slowly on syringe to withdraw fluid. Do not introduce saline through blue “pigtail” air vent of Salem sump tube. Checking placement before instillation of normal saline prevents accidental entrance of irrigating solution into lungs. Draw up 30 mL of normal saline into Asep- to syringe to minimize loss of electrolytes from stomach fluids. DIF:Apply (application)REF:1177 OBJ: Discuss nursing care measures required for patients with a bowel diversion. TOP: Implementation MSC: Physiological Adaptation 28. The nurse administers a cathartic to a patient. Which finding helps the nurse determine that the cathartic has a therapeutic effect? a. Reports decreased diarrhea. b. Experiences pain relief. c. Has a bowel movement. d. Passes flatulence. ANS: C A cathartic is a laxative that stimulates a bowel movement. It would be effective if the patient experiences a bowel movement. The other options are not outcomes of administration of a cathartic. An antidiarrheal will provide relief from diarrhea. Pain medications will provide pain relief. Carminative enemas provide relief from gaseous distention (flatulence). DIF:Analyze (analysis)REF:1151 | 1163 OBJ: Use critical thinking in providing care to patients with alterations in bowel elimination. TOP:EvaluationMSC harmacological and Parenteral Therapies 29. An older adult’s perineal skin is dry and thin with mild excoriation. When providing hygiene care after episodes of diarrhea, what should the nurse do? a. Thoroughly scrub the skin with a washcloth and hypoallergenic soap. b. Tape an occlusive moisture barrier pad to the patient’s skin. c. Apply a skin protective ointment after perineal care. d. Massage the skin with light kneading pressure. ANS: C Cleansing with a no-rinse cleanser and application of a barrier ointment should be done after each episode of diarrhea. Tape and occlusive dressings can damage skin. Excessive pressure and massage are inappropriate and may cause skin breakdown. DIF:Apply (application)REF:1169 OBJ:List nursing interventions that promote normal elimination. TOP: Implementation MSC: Basic Care and Comfort 30. Which action will the nurse take to reduce the risk of excoriation to the mucosal lining of the patient’s nose from a nasogastric tube? a. Instill Xylocaine into the nares once a shift. b. Tape tube securely with light pressure on nare. c. Lubricate the nares with water-soluble lubricant. d. Apply a small ice bag to the nose for 5 minutes every 4 hours. ANS: C The tube constantly irritates the nasal mucosa, increasing the risk of excoriation. Frequent lubrication with a water-soluble lubricant decreases the likelihood of excoriation and is less toxic than oil-based if aspirated. Xylo- caine is used to treat sore throat, not nasal mucosal excoriation. While the tape should be secure, pressure will increase excoriation. Ice is not applied to the nose. DIF:Apply (application)REF:1175 OBJ: Discuss nursing care measures required for patients with a bowel diversion. TOP: Implementation MSC: Basic Care and Comfort 31. A nurse is providing discharge teaching for a patient who is going home with a guaiac test. Which statement by the patient indicates the need for further education? a. “If I get a blue color that means the test is negative.” b. “I should not get any urine on the stool I am testing.” c. “If I eat red meat before my test, it could give me false results.” d. “I should check with my doctor to stop taking aspirin before the test.” ANS: A A blue color indicates a positive guaiac, or presence of fecal occult blood; the patient needs more teaching to correct this misconception. Proper patient education is important for viable results. Be sure specimen is free of toilet paper and not contaminated with urine. The patient needs to avoid certain foods, like red meat, to rule out a false positive. While the health care provider should be consulted before asking a patient to stop any medication, if there are no contraindications, the patient should be instructed to stop taking aspirin, ibuprofen, naproxen or other nonsteroidal antiinflammatory drugs for 7 days because these could cause a false-positive test result. DIF:Apply (application)REF:1157-1158 OBJ: Describe nursing implications for common diagnostic examinations of the gastrointestinal tract. TOP: Eval- uation MSC: Reduction of Risk Potential 32. A nurse is preparing to lavage a patient in the emergency department for an overdose. Which tube should the nurse obtain? a. Ewald b. Dobhoff c. Miller-Abbott d. Sengstaken-Blakemore ANS: A Lavage is irrigation of the stomach in cases of active bleeding, poisoning, or gastric dilation. The types of tubes include Levin, Ewald, and Salem sump. Sengstaken-Blakemore is used for compression by internal application of pressure by means of inflated balloon to prevent internal esophageal or GI hemorrhage. Dobhoff is used for enteral feeding. Miller-Abbott is used for gastric decompression. DIF:Apply (application)REF:1167 OBJ: Discuss nursing care measures required for patients with a bowel diversion. TOP lanningMSC:Management of Care 33. The nurse is caring for a patient with Clostridium difficile. Which nursing actions will have the greatest im- pact in preventing the spread of the bacteria? a. Appropriate disposal of contaminated items in biohazard bags b. Monthly in-services about contact precautions c. Mandatory cultures on all patients d. Proper hand hygiene techniques ANS: D Proper hand hygiene is the best way to prevent the spread of bacteria. Soap and water are mandatory. Month- ly in-services place emphasis on education, not on action. Biohazard bags are appropriate but cannot be used on every item that C. difficile comes in contact with, such as a human. Mandatory cultures are expensive and unnecessary and would not prevent the spread of bacteria. DIF:Apply (application)REF:1152 OBJ: Discuss psychological and physiological factors that influence the elimination process. TOP: Implementation MSC: Safety and Infection Control 34. A nurse is performing an assessment on a patient who has not had a bowel movement in 3 days. The nurse will expect which other assessment finding? a. Hypoactive bowel sounds b. Increased fluid intake c. Soft tender abdomen d. Jaundice in sclera ANS: A Three or more days with no bowel movement indicates hypomotility of the GI tract. Assessment findings would include hypoactive bowel sounds, a firm distended abdomen, and pain or discomfort upon palpation. In- creased fluid intake would help the problem; a decreased intake can lead to constipation. Jaundice does not oc- cur with constipation but can occur with liver disease. DIF:Apply (application)REF:1152 | 1157 | 1161 OBJ: Assess a patient’s elimination pattern. TOP: Assessment MSC: Physiological Adaptation 35. A nurse is caring for a patient who has had diarrhea for the past week. Which additional assessment finding will the nurse expect? a. Distended abdomen b. Decreased skin turgor c. Increased energy levels d. Elevated blood pressure ANS: B Chronic diarrhea can result in dehydration. Patients with chronic diarrhea are dehydrated with decreased skin turgor and blood pressure. Diarrhea also causes loss of electrolytes, nutrients, and fluid, which decreases ener- gy levels. A distended abdomen could indicate constipation. DIF:Apply (application)REF:1152 OBJ: Assess a patient’s elimination pattern. TOP: Assessment MSC: Physiological Adaptation 36. The nurse is caring for a patient who had a colostomy placed yesterday. The nurse should report which as- sessment finding immediately? a. Stoma is protruding from the abdomen. b. Stoma is flush with the skin. c. Stoma is purple. d. Stoma is moist. ANS: C A purple stoma may indicate strangulation/necrosis or poor circulation to the stoma and may require surgical intervention. A stoma should be reddish-pink and moist in appearance. It can be flush with the skin, or it can protrude. DIF:Apply (application)REF:1181 OBJ: Discuss nursing care measures required for patients with a bowel diversion. TOP:AssessmentMSC:Management of Care 37. A patient is receiving a neomycin solution enema. Which primary goal is the nurse trying to achieve? a. Prevent gaseous distention b. Prevent constipation c. Prevent colon infection d. Prevent lower bowel inflammation ANS: C A medicated enema is a neomycin solution, i.e., an antibiotic used to reduce bacteria in the colon before bowel surgery. Carminative enemas provide relief from gaseous distention. Bulk forming, emollient (wetting), and os- motic laxatives and cathartics help prevent constipation or treat constipation. An enema containing steroid medication may be used for acute inflammation in the lower colon. DIF:Apply (application)REF:1165 OBJ: Use critical thinking in providing care to patients with alterations in bowel elimination. TOP: Planning MSC: Basic Care and Comfort 38. A guaiac test is ordered for a patient. Which type of blood is the nurse checking for in this patient’s stool? a. Bright red blood b. Dark black blood c. Microscopic d. Mucoid ANS: C Fecal occult blood tests are used to test for blood that may be present in stool but cannot be seen by the naked eye (microscopic). This is usually indicative of a gastrointestinal bleed. All other options are incorrect. Detecting bright red blood, dark black blood, and blood that contains mucus (mucoid) is not the purpose of a guaiac test. DIF:Understand (comprehension)REF:1156 OBJ: Describe nursing implications for common diagnostic examinations of the gastrointestinal tract. TOP: As- sessment MSC: Physiological Adaptation 39. A patient is receiving opioids for pain. Which bowel assessment is a priority? a. Clostridium difficile b. Constipation c. Hemorrhoids d. Diarrhea ANS: B Patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipa- tion. C. difficile occurs from antibiotics, not opioids. Hemorrhoids are caused by conditions other than opioids. Diarrhea does not occur as frequently as constipation. DIF:Apply (application)REF:1152 OBJ: Assess a patient’s elimination pattern. TOP: Assessment MSC harmacological and Parenteral Therapies 40. Which nutritional instruction is a priority for the nurse to advise a patient about with an ileostomy? a. Keep fiber low. b. Eat large meals. c. Increase fluid intake. d. Chew food thoroughly. ANS: C Patients with ileostomies will digest their food completely but will lose both fluid and salt through their stoma and will need to be sure to replace this to avoid dehydration. A good reminder for patients is to encourage drinking an 8-ounce glass of fluid when they empty their pouch. This helps patients to remember that they have greater fluid needs than they did before having an ileostomy. A low-fiber diet is not necessary. Eating large meals is not advised. While chewing food thoroughly is correct, it is not the priority; liquid is the priority. DIF:Analyze (analysis)REF:1168 OBJ: Discuss nursing care measures required for patients with a bowel diversion. TOP: Teaching/Learning MSC: Reduction of Risk Potential MULTIPLE RESPONSE 1. A nurse is preparing a bowel training program for a patient. Which actions will the nurse take? (Select all that apply.) a. Record times when the patient is incontinent. b. Help the patient to the toilet at the designated time. c. Lean backward on the hips while sitting on the toilet. d. Maintain normal exercise within the patient’s physical ability. e. Apply pressure with hands over the abdomen, and strain while pushing. f. Choose a time based on the patient’s pattern to initiate defecation-control measures. ANS: A, B, D, F A successful program includes the following: Assessing the normal elimination pattern and recording times when the patient is incontinent. Choosing a time based on the patient’s pattern to initiate defecation-control measures. Maintaining normal exercise within the patient’s physical ability. Helping the patient to the toilet at the designated time. Offering a hot drink (hot tea) or fruit juice (prune juice) (or whatever fluids normally stimu- late peristalsis for the patient) before the defecation time. Instructing the patient to lean forward at the hips while sitting on the toilet, apply manual pressure with the hands over the abdomen, and bear down but do not strain to stimulate colon emptying. DIF:Understand (comprehension)REF:1168 OBJ: List nursing interventions included in bowel training. TOP: Implementation MSC:Health Promotion and Maintenance 2. A nurse is teaching a health class about colorectal cancer. Which information should the nurse include in the teaching session? (Select all that apply.) a. A risk factor is smoking. b. A risk factor is high intake of animal fats or red meat. c. A warning sign is rectal bleeding. d. A warning sign is a sense of incomplete evacuation. e. Screening with a colonoscopy is every 5 years, starting at age 50. f. Screening with flexible sigmoidoscopy is every 10 years, starting at age 50. ANS: A, B, C, D Risk factors for colorectal cancer are a diet high in animal fats or red meat and low intake of fruits and vegeta- bles; smoking and heavy alcohol consumption are also risk factors. Warning signs are change in bowel habits, rectal bleeding, a sensation of incomplete evacuation, and unexplained abdominal or back pain. A flexible sig- moidoscopy is every 5 years, starting at age 50, while a colonoscopy is every 10 years, starting at age 50. DIF:Understand (comprehension)REF:1162 OBJ escribe common physiological alterations in elimination. TOP: Teaching/Learning MSC: Health Promotion and Maintenance [Show More]

Last updated: 1 year ago

Preview 1 out of 29 pages