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foundaton ch.38
| Question | Answer |
|---|---|
| A nurse is caring for a client with primary constipation. Which factor is responsible for primary constipation? | inadequate intake of liquid |
| Which symptom is a known side effect of antibiotics? | Diarrhea |
| Which statement about ostomy irrigation is true? | For some clients, regularly scheduled colostomy irrigation can be used to establish a predictable pattern of elimination. |
| The newly hired graduate nurse is preparing to administer a cleansing enema. The nurse educator will intervene if which action is taken by the graduate nurse? | The graduate places the client in Fowler’s position. |
| While administering a cleansing enema, the client displays lightheadedness, nausea, and has clammy skin. The nurse would implement which priority action? | Stop the procedure, monitor heart rate and blood pressure. |
| The nurse is scheduling tests for a client who is experiencing bowel alterations. What is the most logical sequence of tests to ensure an accurate diagnosis? | fecal occult blood test, barium studies, endoscopic examination |
| A client is preparing for a fecal occult blood test. What teaching will the nurse provide regarding vitamin C three days before testing? | Avoid more than 250 mg |
| A nurse prepares to insert a nasointestinal tube to provide nutrition to a client. Which guideline is recommended for this procedure? | Begin by measuring from the tip of the client's nose to the earlobe to the xiphoid process. |
| The nurse is slowly advancing a nasogastric (NG) tube when the client begins to gasp and is unable to vocalize. Which scenario has likely occurred? | The NG tube is in the client’s airway. |
| The nurse needs to collect a stool specimen for culture from a client. The client passed stool into the toilet instead of using the collection container. What is the next step for the nurse? | Reinstruct the client on use of collection container for next bowel movement. |
| he nurse is preparing to auscultate the bowel sounds of a client with a nasogastric tube in place set to low intermittent suction. How shall the nurse approach the assessment of bowel sounds | Disconnect the nasogastric tube from suction during the assessment of bowel sounds. |
| The nurse is educating a new colostomy client on gas-producing foods. Which food is a gas-producing food the client may choose to avoid? | brussels sprouts |
| A nurse is giving an enema to a client who doubles over in pain with severe cramping. What intervention would be appropriate in this situation? | Lower the solution container and check the temperature and flow rate. |
| The student nurse is administering a large-volume enema to a client. The client reports abdominal cramping. What should the student nurse do first? | Stop the administration of the enema momentarily. |
| When reviewing a client’s chart, which data related to a client experiencing diarrhea might suggest to the nurse a causative factor? | The client returned from a foreign country 2 days ago. |
| A client has been given fecal occult blood test (FOBT) testing supplies. What teaching will the nurse provide about the purpose for this test? | “This test detects heme, an iron compound in blood within the stool.” |
| An older adult client tells the nurse, “I give myself a mineral oil enema every day.” What is the appropriate nursing response? | “Mineral oil enemas can interfere with absorption of fat-soluble vitamins.” |
| A nurse assesses a client with an ostomy appliance and notes that the stoma is protruding into the bag. How should the nurse respond to this assessment finding? | Have the client rest for half an hour and then reassess. |
| A registered nurse is overseeing the care of numerous clients on an acute medicine unit. Which task should the nurse delegate to unlicensed assistive personnel (UAP)? | Emptying a client's ileostomy appliance |
| A client has had abdominal surgery and 72 hours later develops abdominal distention and absence of bowel sounds with pain. The nurse suspects the client has: | paralytic ileus. |
| When caring for a client with fecal incontinence, the nurse knows that fecal incontinence is the result of: | physiologic or lifestyle changes in the client. |
| The nurse is preparing a client to receive a hypertonic enema solution. Into which position will the nurse place the client? | Sims |
| A client wishes to increase fiber to promote more regular bowel movements. Which food will the nurse recommend that the client consume? | brown rice |
| A client is not having a bowel movement daily. The client perceives being constipated. Which assessment data is the nurse likely to collect from this client? Select all that apply. | chronic purging using laxatives several times daily |
| A client scheduled for a colonoscopy is scheduled to receive a hypertonic enema prior to the procedure. A hypertonic enema is classified as which type of enema? | cleansing enema |
| Which statement best explains why digital removal of stool is considered a last resort after other methods of bowel evacuation have been unsuccessful? | Digital removal of stool may cause parasympathetic stimulation. |
| The nurse is caring for an older adult client with diarrhea. Which assessment finding requires immediate nursing intervention? | skin turgor response 5 seconds |
| The nurse prepares to administer large-volume cleansing enemas to a client scheduled for bowel surgery. For which client should the nurse stop administration of the enemas and notify the primary care provider? | the client who experiences severe abdominal pain |
| A nurse is caring for a client with an NG tube attached to continuous suction. The nurse observes that the tube is connected to the wall suction, but it is not draining. What is the nurse's best action? | Attempt to irrigate the NG tube with water or normal saline. |
| The nurse is preparing to auscultate the bowel sounds of a client with a nasogastric tube in place set to low intermittent suction. How shall the nurse approach the assessment of bowel sounds and manage the nasogastric tube? | Disconnect the nasogastric tube from suction during the assessment of bowel sounds. |
| Which medication causes constipation? | Iron supplements |
| The type of stool that will be expelled into the ostomy bag by a client who has undergone surgery for an ileostomy will be: | liquid consistency. |
| The health care provider prescribes a high-fiber diet for a client to promote bowel elimination. Which foods, selected by the client, would indicate to the nurse that the client can identify high-fiber foods? | Whole wheat spaghetti and broccoli |
| The newly hired graduate nurse is preparing to administer a cleansing enema. The nurse educator will intervene if which action is taken by the graduate nurse? | The graduate places the client in Fowler’s position. |
| While administering a cleansing enema, the client displays lightheadedness, nausea, and has clammy skin. The nurse would implement which priority action? | Stop the procedure, monitor heart rate and blood pressure. |
| The nurse is doing preoperative teaching with a client who has a prescription for GoLYTELY® before undergoing intestinal surgery. For tolerance of drinking the solution, the nurse would advise the client to drink it in which manner? | chilled |
| After data collection on a client, the nurse suspects that the client has diarrhea. Which data collection finding, if observed by the nurse, would confirm the nurse's suspicion? | Hyperactive bowel sounds |
| The nurse is inserting a rectal tube to administer a large-volume enema. Which nursing action is performed correctly in this procedure? | Slowly and gently insert the enema tube 3 to 4 in (7.5 to 10 cm) for an adult. |
| A client's last bowel movement was 4 days ago and oral laxatives and dietary changes have failed to prompt a bowel movement. How should the nurse position the client in anticipation of administering a cleansing enema? | left side-lying |
| A nurse has auscultated the abdomen in all four quadrants for 5 minutes and has not heard any bowel sounds. How would this be documented? | “All four abdominal quadrants auscultated. Inaudible bowel sounds.” |
| A nurse is caring for a client with an ostomy pouch. When should the nurse ask the client to empty the pouch? | when the pouch is one-third to one-half full |
| An older adult woman who is incontinent of stool following a cerebrovascular accident will have which nursing diagnosis? | Bowel Incontinence related to loss of sphincter control, as evidenced by inability to delay the urge to defecate |
| The nurse is presenting a lecture on ostomy bowel elimination at a community clinic. When questioned by the clients, which food would the nurse suggest as natural intestinal deodorizers? | Yogurt and buttermilk |
| The nurse is changing a client’s ostomy appliance and observes that the peristomal skin is excoriated. What would be the nurse’s priority intervention in this situation? | Make sure that the appliance is not cut too large. |
| A nurse is caring for a client whose primary care provider has written an order for "enemas until clear." Which explanation to the client about this procedure is correct? | "I will administer enemas until the enema return is without stool." |
| Which client is most likely to require interventions in order to maintain regular bowel patterns? | a client whose neuropathic pain requires multiple doses of opioids each day |
| During the inspection of a client's abdomen, the nurse notes that it is visibly distended. The nurse should proceed with the client's abdominal assessment by next performing: | auscultation |
| The home care nurse visits a client and is reviewing the medications that the client uses. Which medication would the nurse identify as acting directly on the intestine to slow bowel motility, or to absorb excess fluid in the bowel? | Antidiarrheal agent |
| The nurse is providing health teaching for four clients. Which client should consider a colonoscopy screening? | 50-year-old client with a family history of polyps |
| A nurse is caring for a client who has a large, hardened mass of stool interfering with defecation, making it impossible for the client to pass feces voluntarily. How should the nurse document this condition? | fecal impaction |
| A cleansing enema has been ordered for the client to draw water into the bowel. Which type of solution does the nurse gather? | hypertonic saline |
| When caring for a client with a new colostomy, which assessment finding would be considered abnormal and would need to be reported to the physician? | The stoma is prolapsed. |
| A student nurse studying human anatomy knows that a structure of the large intestine is the: | cecum |
| A nurse is teaching a client how to change his ostomy appliance. Which instructions should be incorporated into the teaching plan? | Use toilet tissue to remove any excess stool from the stoma. |
| A nurse is performing an abdominal assessment of a client before administering a large-volume cleansing enema. Which assessment technique would be performed last? | Palpation |
| The nurse is caring for a client who is scheduled for an esophagogastroduodenoscopy (EGD). What action would the nurse take to prepare the client for this procedure? | Ensure that the client fasts 6 to 12 hours before the test as per policy. |
| A nurse is teaching a student nurse how to manage unexpected events during the removal of a nasogastric tube. Which action should the nurse recommend? | If within 2 hours after NG tube removal, the client's abdomen is showing signs of distention, notify the health care provider. |
| The nurse has just confirmed proper placement of a nasogastric tube. Which action should the nurse take next? | Apply skin barrier to the tip and end of the nose. |
| The nurse is administering a rectal suppository. How far will the nurse insert the suppository? | past the internal sphincter |
| A nurse is collecting a stool specimen of a client suspected of having Clostridium difficile. Which guideline is recommended for this procedure? | Collect 15 to 30 mL of the client's liquid stool. |
| When a client reveals to a nurse during data collection that his stools are speckled, which appropriate question might the nurse ask the client? | “Do you frequently take antacids?” |
| A client reports experiencing uncomfortable, frequent episodes of flatulence to the nurse. Which foods will the nurse recommend that the client avoid? Select all that apply. | cucumbers lentils onions cabbage |
| Which medical diagnosis is most likely to necessitate testing for fecal occult blood? | Peptic Ulcer |
| The nursing student is performing a focused gastrointestinal assessment. Which action performed by the student would indicate to nurse faculty that further instruction is needed? | The student sequenced from auscultation to inspection, and percussion to palpation. |
| The nursing instructor is having a discussion related to the gastrointestinal (GI) system. Which statements by the students would indicate that the discussion was effective? Select all that apply. | “Movement of the colon is stimulated by the parasympathetic nervous system.” “The last part of the large intestine is the rectum, not the anus.” “The stool becomes hard if it remains in the large intestine too long.” |
| The nurse is evaluating stool characteristics of an adult client. Which color stool does the nurse identify as abnormal? Select all that apply. | black clay colored yellow |
| The nurse is talking with four members of a family. Which client within the family does the nurse identify that would benefit from discussing a colonoscopy screening with their health care provider? | 47-year old whose father had polyps |
| A student nurse is preparing to administer a client's ordered large-volume enema. What action should the nurse perform during this skill? | Administer the solution gradually over 5 to 10 minutes. |
| For which client would digital removal of stool be contraindicated? | a client recovering from prostate surgery |
| A nurse is collecting a stool specimen of a client suspected of having Clostridium difficile. Which guideline is recommended for this procedure? | Collect 15 to 30 mL of the client's liquid stool. |
| "Vagal response" is the voluntary increase of intra-abdominal pressure that helps expel feces. T or F? | false |
| The student nurse has completed a presentation to a group of senior citizens on colorectal screening. Which statement by a participant suggests a need for further education? | "I will have a fecal occult blood test done every 5 years." |
| The nurse is teaching a client with diarrhea about dietary management. Which teaching will the nurse include? Select all that apply. | Choose bland foods, such as cottage cheese. Bananas and applesauce are appropriate. |
| The nurse has provided instructions to a client having a fecal immunochemical test (FIT). The client states, "I am menstruating right now. Is it okay to still do the test?" What is the best response by the nurse? | “Wait to do the test 3 days after your finish menstruating.” |
| A nurse is following a health care provider's order to irrigate a client's NG tube. Which guideline is recommended in this procedure? | Assist the client to a 30- to 45-degree position, unless this is contraindicated. |
| The nurse is replacing a client's ileostomy appliance and has identified that the diameter of the stoma is 3.5 cm. The nurse has trimmed the flange of the new appliance to a diameter of 7 cm. What will be the most likely outcome of this | A risk that the peristomal skin will become excoriated |
| A nurse prepares to collect a stool sample from a client to test for fecal fat. Which guideline accurately describes a consideration in this process? | The entire amount of stool produced for 24 to 72 hours should be sent to the laboratory. |
Created by:
briannagrace