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Bowel Elimination
| Question | Answer |
|---|---|
| If a patient had to have part of the colon (large intestine) removed, which of the following may result? | The patient could experience an acid-base imbalance. |
| A nurse is admitting a patient to the unit. The nurse is aware that the patient is at increased risk for constipation if the following are present in the patient's health history or admission assessment: (Select all that apply.) | The patient is an elderly woman. The patient takes opioids for chronic back pain. The patient takes daily iron and calcium supplements. |
| A student nurse is studying the GI system in preparation for an exam. Which statement indicates correct understanding? | The ascending colon would be found in the right side of the patient s abdomen. |
| An increase in venous pressure caused by liver disease can result in the development of: | Hemorrhoids |
| The comatose patient in the intensive care unit (ICU), who has not had a bowel movement in 4 days, suddenly is incontinent of liquid stool. What should the nurse suspect? | Impaction |
| The nurse is monitoring the patient for a possible vagal response while removing a fecal impaction. If the patient had a vagal response, what would the nurse most likely observe? | A decrease in heart rate. |
| An adult patient is scheduled for an abdominal computed tomography (CT) scan. Before the scan he must receive a cleansing tap water enema. The nurse should prepare: | 1000 mL or less of tap water. |
| The health care provider has ordered a Fleet enema for a patient experiencing constipation. Which of the following actions would require correction? | The nurse squeezes and releases the bottle several times until all of the solution has entered the patient. |
| An adult patient complains of cramping during the administration of an enema. What could be a possible cause? (Select all that apply.) | The solution was instilled too rapidly. The enema solution was too cold. |
| Which of the following is the best example of documentation of enema administration? | 0830 800 mL tap water enema administered. Return clear with no fecal material Bowel sounds present in all 4 quadrants pre and post procedure. Abdomen nondistended. Patient states "I’m glad that’s over." |
| The nurse is observing the NAP administer a soap suds enema to an adult patient. Which of the following actions, if made by the NAP, would require correction? | The NAP inserts the tip of the rectal tube 5 to 7 inches after lubricating it. |
| A patient is to receive enemas "until clear." The nurse notes that stool remains in the fecal return after the second enema. What should the nurse do? | Administer a third enema. |
| An infant is to have an enema. Which solution would the nurse anticipate using? | Normal saline. |
| A patient has a loop colostomy. The patient complains that the distal stoma looks like it is secreting mucus. What is your best response? | "The distal stoma may secrete mucus and that would be normal." |
| A patient has been admitted for surgery for a colostomy. The patient states, "I can’t believe this has happened to me." What is the nurse’s best response? | "It will be a change for you, but a normal lifestyle is still possible. What concerns you the most?" |
| A patient is scheduled to have an ileostomy. The patient asks, "Will I always have to wear a pouch?" What is the nurse’s best response? | "Unless an internal pouch is surgically created, the effluent of an ileostomy is very liquid and must be pouched at all times." |
| The nurse is pouching an enterostomy. Assuming all other steps are performed correctly, which of the following steps is incorrect? | The nurse cleans the peristomal skin vigorously with warm tap water, selects a pouch, removes the backing and cuts the opening on the pouch to one-quarter inch larger than the stoma. |
| When is the best time to change the skin barrier pouch? (Select all that apply.) | Several hours after breakfast. Several hours after lunch. |
| Identify the equipment needed to pouch an enterostomy by using a precut system. (Select all that apply.) | Gauze pads/washcloth. Towel/disposable waterproof barrier. Basin with warm tap water. Pouch closure device/such as a clamp. Clean gloves. Pouch clear drainable colostomy/ileostomy in correct size for 2 piece system or 1 piece type w/ attached skin barrier |
| Identify interventions for irritation around the stoma. (Select all that apply.) | good seal of the skin barrier/pouching system so that undermining of fecal contents will be avoided. the patient’s skin is reacting to adhesive removal. Consult the ostomy care nurse. different type of pouching system is needed to prevent leakage. |
| Nursing assistive personnel (NAP) reports the patient's stoma appears purple. What would likely be the cause? | A lack of circulation to the stoma. |
| The nurse is teaching the patient how to pouch an ostomy. Which statement, if made by the patient, indicates further instruction is needed? | “I should clean the peristomal skin with soap and warm water.” |
Created by:
Elacio