Chapter 34: Bowel Elimination and Gastric Intubation Nursing School Test Banks

MULTIPLE CHOICE

1. The nurse is caring for a patient who has been on bed rest for several weeks. The nurse notes that the patient is continually seeping liquid stool rectally. The nurse should take which action?

a.

Hold the patients antibiotics.

b.

Put the patient on a bran diet.

c.

Perform a digital rectal examination.

d.

Increase the dosage of the patients antibiotics.

ANS: C

Continual seepage of diarrhea may occur with an impaction, and a digital rectal examination can verify its presence. Diarrhea is often due to diet or antibiotic use, which alters the normal flora in the gastrointestinal tract. However, a physicians order is required to change these, and continual seepage of stool is more likely the result of impaction; this should be ruled out first.

DIF: Cognitive Level: Application REF: Text reference: p. 849

OBJ: Discuss methods used to relieve constipation or impaction.

TOP: Digital Rectal Examination KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

2. The patient is a 74-year-old man who has been in the hospital for 4 days following an orthopedic surgical procedure. He is concerned because he has not moved his bowels every day as he did before surgery, but every other day. Which response made by the nurse is appropriate?

a.

Tells the patient to put himself on over-the-counter laxatives

b.

Tells the patient that daily bowel movements are not always necessary

c.

Tells the patient that with increasing age, his bowel movements should increase in frequency

d.

Tells the patient that she will call to get a laxative to get him back on track

ANS: B

Reinforce with older adult patients that as long as the consistency of the stool remains normal and bowel movements occur with regularity. As long as he is able to move his bowels at least 3 times a week, he shouldnt worry about not having a daily movement. Since there is no indication of constipation the patient should not place himself on laxatives. However, since the patient is most likely less mobile and receiving strong pain medication following his orthopedic surgery (both likely to cause constipation) the nurse should monitor the situation.

DIF: Cognitive Level: Application REF: Text reference: pp. 842-843

OBJ: Discuss methods used to relieve constipation or impaction.

TOP: Gerontological Considerations KEY: Nursing Process Step: Intervention

MSC: NCLEX: Physiological Integrity

3. The nurse assesses that a patient has a severe fecal impaction. Which action taken by the nurse addresses this problem?

a.

Administering laxatives

b.

Providing a high-fiber diet

c.

Performing a digital removal

d.

Administering an enema

ANS: C

Prevention is the key to fecal impaction. However, once it occurs, digital removal of stool is the only alternative. Once the impaction is cleared, a high-fiber diet, increased activity, and adequate hydration may all reduce the likelihood of recurrence.

DIF: Cognitive Level: Application REF: Text reference: p. 849

OBJ: Describe factors that promote and impede normal bowel elimination.

TOP: Digital Removal of Fecal Impaction

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

4. The nurse prepares to exercise a digital removal of feces. To detect an untoward effect of this procedure, the nurse should assess the patient history for which condition?

a.

Heart disease

b.

Abdominal pain

c.

Urinary infection

d.

Diabetes mellitus

ANS: A

Because of the potential to stimulate the vagus nerve, patients with a history of dysrhythmia or heart disease are at greater risk for changes in heart rhythm. Be sure to monitor the patients pulse before and during the procedure. This procedure may be contraindicated in cardiac patients; if in doubt, verify with the physician. Symptoms of fecal impaction include constipation, rectal discomfort, anorexia, nausea, vomiting, abdominal pain, diarrhea (around the impacted stool), and urinary frequency. Abdominal pain by itself is not indicative of the need for extra caution. Symptoms of fecal impaction include urinary frequency, not infection. There is no correlation between the two.

DIF: Cognitive Level: Analysis REF: Text reference: pp. 849-850

OBJ: Describe factors that promote and impede normal bowel elimination.

TOP: Digital Removal of Fecal Impaction

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

5. When evaluating a health care team members ability to digitally remove feces, the nurse determined that further teaching is required in which of the following situations?

a.

Staff member provides perianal skin care.

b.

Staff member continues the procedure if bleeding starts.

c.

Staff member follows the procedure by offering the patient the bedpan.

d.

Staff member discontinues the procedure in the presence of bradycardia.

ANS: B

If the patient experiences bleeding from the rectum, the anal and perianal regions should be assessed to locate the source of the bleeding. Observe for the presence of perianal skin irritation. The presence of such indicates the need for postprocedure skin care to the perianal region to reduce pain during subsequent bowel elimination. After the procedure, assist the patient to the toilet or onto a clean bedpan. Removal of impaction stimulates the defecation reflex. The sacral branch of the vagus nerve is stimulated during digital stimulation; this may result in reflex slowing of the heart rate. Stop the procedure and retake vital signs.

DIF: Cognitive Level: Analysis REF: Text reference: p. 851

OBJ: Implement the following skills: digital removal of stool.

TOP: Digital Removal of Fecal Impaction

KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity

6. The nurse is preparing to administer an enema to a patient. Which type of enema is most likely to lead to circulatory overload?

a.

Hypertonic solution

b.

Soapsuds

c.

Tap water

d.

Harris flush

ANS: C

A tap water (hypotonic) enema should not be repeated after first instillation because water toxicity or circulatory overload can develop. Hypertonic solution is useful for patients who cannot tolerate large volumes of fluid. Only 120 to 180 mL (4 to 6 ounces) is usually effective (e.g., commercially prepared Fleet enema). A soapsuds enema (SSE) consists of pure castile soap added to tap water or normal saline, depending on the patients condition and the frequency of administration. Use only castile pure soap. The recommended ratio of pure soap to solution is 5 mL (1 teaspoon) to 1000 mL (1 quart) warm water or saline. Add soap to the enema bag after water is in place to reduce excessive suds. The Harris flush enema is a return-flow enema that helps to expel intestinal gas. Fluid alternately flows into and out of the large intestine. This stimulates peristalsis in the large intestine and assists in expelling gas.

DIF: Cognitive Level: Analysis REF: Text reference: p. 852

OBJ: Implement the following skills: enema administration. TOP: Tap Water Enema

KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity

7. When preparing an infant for an enema, the nurse understands that which solution is the safest?

a.

Tap water enema solution

b.

Hypertonic enema solution

c.

Oil retention

d.

Physiological normal saline

ANS: D

Physiological normal saline is safest. Infants and children can tolerate only this type because of their predisposition to fluid imbalance. If solution is prepared at home, mix 500 mL (1 pt) of tap water with 1 teaspoon of table salt. None of the other types of enemas are safe to use for infants and children.

DIF: Cognitive Level: Analysis REF: Text reference: p. 852

OBJ: Implement the following skills: enema administration. TOP: Saline Enema

KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

8. The patient is being prepped for surgery and has an order for enemas until clear. The nurse realizes that she will be giving a maximum of how many enemas?

a.

One

b.

Two

c.

Three

d.

Four

ANS: C

The enemas until clear order means that you repeat enemas until the patient passes fluid that is clear of fecal matter. Check agency policy, but usually a patient should receive a maximum of three consecutive enemas to avoid disruption of fluid and electrolyte balance. If more are required, notify the physician before administering.

DIF: Cognitive Level: Application REF: Text reference: p. 853

OBJ: Implement the following skills: enema administration. TOP: Enemas Until Clear

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

9. The nurse is preparing to administer an enema to an adult patient who has normal sphincter control. For administration of the enema, the patient is placed in which position?

a.

Right side-lying

b.

Dorsal recumbent

c.

Sims

d.

Prone

ANS: C

Assist the patient into left side-lying (Sims) position with the right knee flexed. Additionally, place a child in dorsal recumbent position. This allows enema solution to flow downward by gravity along the natural curve of the sigmoid colon and rectum, thus improving retention of solution.

DIF: Cognitive Level: Application REF: Text reference: p. 854

OBJ: Implement the following skills: enema administration. TOP: Enema Process: Positioning

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

10. The nurse has been directed to provide an enema for an elderly female patient who has very poor rectal sphincter control. Which position is most appropriate for this patient?

a.

Sims position

b.

Dorsal recumbent position on the bedpan

c.

Sitting on the toilet

d.

Right lateral position

ANS: B

If the patient has poor sphincter control, position the patient on the bedpan in a comfortable dorsal recumbent position. Patients with poor sphincter control cannot retain all of the enema solution. Administering an enema with the patient sitting on the toilet is unsafe because curved rectal tubing can abrade the rectal wall.

DIF: Cognitive Level: Application REF: Text reference: p. 853

OBJ: Implement the following skills: enema administration.

TOP: Dorsal Recumbent Position on the Bedpan

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

11. When preparing an adult patient for an enema, the nurse understands that the tube or nozzle should be inserted how far?

a.

1 to inches

b.

2 to 3 inches

c.

3 to 4 inches

d.

4 to 5 inches

ANS: C

Insert the nozzle of the container gently into the anal canalfor adults, 7.5 to 10 cm (3 to 4 inches). If administering to an infant, insert the tip of the tube 2.5 to 3.75 cm (1 to inches). If administering to a child, insert the tip of the tube 5 to 7.5 cm (2 to 3 inches). However, children and infants usually do not receive prepackaged hypertonic enemas because hypertonic solutions cause rapid fluid shift. Inserting the tip of the tube more than 4 inches is not appropriate at any age.

DIF: Cognitive Level: Application REF: Text reference: p. 854

OBJ: Implement the following skills: enema administration. TOP: Insertion of Tubing

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

12. While the nurse is administering an enema with a standard enema bag, which intervention is important to implement?

a.

Keeping the solution at room temperature

b.

Positioning the patient on the right side

c.

Raising the enema bag to 12 inches above the patient

d.

Instructing the patient to release the enema solution as soon as possible

ANS: A

Maintaining a the correct temperature for the solution is a critical safety precaution. If the solution is too hot it will burn the intestinal mucosa. Cold water can cause abdominal cramping. Solution dripped on inner wrist should be comfortable. Unless patient condition requires a different position, the patient will lay on his/her left side with the top leg flexed (left lateral Sims) and the bag of solution will be hung 18 inches above the rectum. The patient will be instructed to retain the solution as long as possible for maximum therapeutic effect.

DIF: Cognitive Level: Application REF: Text reference: pp. 854-855

OBJ: Implement the following skills: enema administration. TOP: Temperature of Solution

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

13. While the nurse is administering an enema, the patient complains of some cramping. Which action should the nurse take next?

a.

Discontinue the procedure completely.

b.

Increase the height of the solution.

c.

Slow the rate of infusion.

d.

Have the patient roll into a supine position.

ANS: A

If abdominal cramping develops, decrease the height of the enema bag and slow the rate of instillation. Changing the patient position will not be helpful. Sometimes, temporarily stopping the solution (taking a break) minimizes cramping.

DIF: Cognitive Level: Application REF: Text reference: pp. 855-856

OBJ: Implement the following skills: enema administration. TOP: Abdominal Cramping

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

14. When providing care for a patient who is disoriented during a nasogastric (NG) tube placement, which intervention is important for the nurse to implement?

a.

Halt the procedure.

b.

Request assistance with insertion.

c.

Administer a hypnotic medication.

d.

Continue the procedure as with any other patient.

ANS: B

If the patient is confused, disoriented, or unable to follow commands, obtain assistance from another staff member to insert the tube.

DIF: Cognitive Level: Application REF: Text reference: p. 858

OBJ: Implement the following skills: insertion of an NG tube. TOP: Disoriented Patient

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

15. When developing a plan of care for a patient requiring an NG tube, the nurse recognizes that it is essential to implement which technique in measuring the length of the tube?

a.

Measure from the nose to the ear to the patients navel.

b.

Measure from the nose to the middle of the sternum.

c.

Measure and mark a point 30 inches from the end.

d.

Mark the 50-cm point on the tube, measure in the traditional way, and insert halfway between the two spots.

ANS: D

Hanson method: First, mark the 50-cm point on the tube, and then do traditional measurement. Tube insertion should be to the midway point between 50 cm (20 inches) and the traditional mark.

DIF: Cognitive Level: Application REF: Text reference: p. 859

OBJ: Implement the following skills: insertion of an NG tube.

TOP: Measuring Tube for Placement KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

16. In advancing the NG tube, which technique provides the safest outcome?

a.

Rotate the tube if resistance is felt.

b.

Advance the tube in between swallows.

c.

Start with the patients head flexed.

d.

Check the tube placement by instilling air and auscultating over the stomach.

ANS: A

If resistance is met, try to rotate the tube and see whether it advances. If there is still resistance, withdraw the tube, allow the patient to rest, relubricate the tube, and insert it into the other naris. Advance the tube 2.5 to 5 cm (1 to 2 inches) with each swallow of water. If the patient is not allowed fluids, instruct him to dry swallow or suck air through a straw. Initially, instruct the patient to extend his neck back against the pillow; insert the tube slowly through the naris with the curved end pointing downward. Verify tube placement. Check agency policy for preferred methods.

DIF: Cognitive Level: Application REF: Text reference: p. 859

OBJ: Implement the following skills: insertion of an NG tube. TOP: Insertion of NG Tube

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

17. When care is provided for a patient with an NG tube in place, which intervention is safest for the nurse to implement?

a.

Tape the tube up and around the ear on the side of insertion.

b.

Secure the tubing to the bed by the patients head.

c.

Mark the tube where it exits the nose.

d.

Change the tubing daily.

ANS: C

Once placement is confirmed, a red mark should be made or place tape on the tube to indicate where the tube exits the nose. The mark or the tube length is to be used as a guide to indicate whether displacement may have occurred. The tube should be taped to the nose, not to the ear. The tubing should be secured to the patients gown, not to the bed, and should not be changed daily, but it may be irrigated daily.

DIF: Cognitive Level: Application REF: Text reference: p. 862

OBJ: Implement the following skills: insertion of an NG tube.

TOP: Marking NG Tube Placement KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

MULTIPLE RESPONSE

1. A patient is admitted for constipation. When planning care for this patient, the nurse recognizes that which interventions would help control constipation? (Select all that apply.)

a.

Increases in activity level

b.

Elimination of laxative use

c.

Decreased dietary fiber

d.

Increased fluids

e.

Timely response to urge to move bowels

ANS: A, B, D, E

Changes in lifestyle that will be helpful to eliminate constipation cycles include increased dietary fiber, increased fluids, moderate exercise, and elimination of laxative use. It is also important to encourage patients to respond to the urge to move bowels when the urge first occurs, since delay may promote constipation.

DIF: Cognitive Level: Analysis REF: Text reference: p. 843

OBJ: Describe factors that promote and impede normal bowel elimination.

TOP: Interventions to Control Constipation

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

2. The patient has increased his fluid and dietary fiber intake and has started a supervised exercise program. However, he is still having problems with constipation. Which of the following would be an effective intervention? (Select all that apply.)

a.

Metamucil

b.

Milk of magnesia

c.

Dulcolax

d.

Mineral oil

e.

Colace

ANS: A, B, C

Use the following stepwise levels of interventions. Bulk-forming laxatives (e.g., psyllium [Metamucil], methylcellulose [Citrucel]) are safe, add bulk to the fecal material, and are used in combination with a saline laxative (e.g., magnesium hydroxide [milk of magnesia]) or an osmotic laxative (e.g., lactulose [Chronulac]). The patient should increase water intake to enhance the effectiveness of bulk-forming laxatives. If constipation continues, stimulant laxatives (e.g., bisacodyl [Dulcolax], senna [Senokot]) usually provide relief. Avoid emollient laxatives, such as mineral oil and Colace, because they are associated with lipoid aspiration pneumonia.

DIF: Cognitive Level: Analysis REF: Text reference: p. 843

OBJ: Discuss methods used to relieve constipation or impaction.

TOP: Laxatives KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

3. The patient is receiving a soapsuds enema but is having a difficult time retaining the fluid. What action should the nurse take? (Select all that apply.)

a.

Give the enema slowly.

b.

Place the patient in the dorsal recumbent position on a bedpan.

c.

Give the enema with the patient on the toilet.

d.

Give the enema in the right lateral position.

e.

Give the enema faster.

ANS: A, B

Give the enema slowly to aid absorption. If the patient is full of stool, retention is difficult. As stool is evacuated, there is more room in the colon for additional fluid. If the patient has poor sphincter control, position the patient on the bedpan in a comfortable dorsal recumbent position. Patients with poor sphincter control cannot retain all of the enema solution. Administering an enema with the patient sitting on a toilet is unsafe because curved rectal tubing can abrade the rectal wall. Enemas are not given to patients in the right lateral position.

DIF: Cognitive Level: Application REF: Text reference: pp. 854-856

OBJ: Implement the following skills: enema administration.

TOP: Inability to Retain Enema Fluid KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

4. The Levin tube and the Salem sump tube are used most commonly for stomach decompression. Which of the following statements about these tubes is true? (Select all that apply.)

a.

Levin tubes have a blue pigtail that functions as an air vent.

b.

These tubes are inserted as a sterile procedure.

c.

The blue air vent should not be used for irrigation.

d.

The Salem sump tube has a blue pigtail that functions as an air vent.

e.

The Salem sump is preferred for stomach decompression.

ANS: C, D, E

The Levin tube is a single-lumen tube with holes near the tip. You connect the tube to a drainage bag or to an intermittent suction device to drain stomach secretions. The Salem sump tube has two lumina: one for removal of gastric contents and one to provide an air vent, which prevents suctioning of gastric mucosa into eyelets at the distal tip of the tube. A blue pigtail is the air vent that connects with the second lumen. Never clamp off the air vent, connect it to suction, or use it for irrigation. NG tube insertion does not require sterile technique. Clean technique is adequate. The Salem sump is preferred for gastric decompression.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 857

OBJ: Implement the following skills: insertion of an NG tube. TOP: Nasogastric (NG) Tube

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

5. What should the nurse do to verify nasogastric (NG) tube placement? (Select all that apply.)

a.

Ask the patient to speak.

b.

Inspect the posterior pharynx.

c.

Aspirate back on the syringe.

d.

Obtain an x-ray of the placement.

e.

Auscultate the lung fields.

ANS: A, B, C, D

While an x-ray examination is the gold standard to verify NG tube placement, there are several steps the nurse can take to gauge correct placement. Ask the patient to speak. If the patient is unable to speak, the NG tube may have passed through the vocal cords. Inspect the posterior pharynx for the presence of a coiled tube. The tube is pliable and will coil up behind the pharynx instead of advancing into the esophagus. Aspirate gently back on the syringe to obtain gastric contents, observing color. Gastric contents are usually cloudy and green but sometimes are off-white, tan, bloody, or brown. Aspiration of contents provides the means to measure fluid pH and thus determine tube tip placement in the GI tract.

DIF: Cognitive Level: Application REF: Text reference: p. 860

OBJ: Implement the following skills: insertion of an NG tube.

TOP: Verifying Position of NG Tube KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

COMPLETION

1. Infrequent bowel movements (less often than every 3 days), difficulty in evacuating feces, inability to defecate, and hard feces are signs of ________________.

ANS:

constipation

Constipation is a symptom, not a disease. Signs of constipation usually include infrequent bowel movements (less often than every 3 days), difficulty in evacuating feces, inability to defecate, and hard feces.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 842

OBJ: Describe factors that promote and impede normal bowel elimination.

TOP: Constipation KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

2. The __________ system is an intrarectal catheter that has a retention cuff, an intraluminal balloon, three pilot balloons, anchor straps, and a port for sampling stool. The purpose of this system is to divert feces away from wounds while providing access for administering rectal medications and irrigations.

ANS:

Actiflo bowel management

One strategy by which to manage diarrhea is the Actiflo Bowel Management system, which diverts feces away from wounds and administers rectal medications and irrigations. This system consists of an intrarectal catheter that has a retention cuff, an intraluminal balloon, three pilot balloons, anchor straps, and a port for sampling stool.

DIF: Cognitive Level: Knowledge REF: Text reference: pp. 843-844

OBJ: Describe factors that promote and impede normal bowel elimination.

TOP: Zassi Bowel Management KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

3. A bedpan that is designed for patients with body or leg casts or for patients restricted from raising their hips (e.g., following total joint replacement) is known as a _____________.

ANS:

fracture pan

A fracture pan, designed for patients with body or leg casts or for those restricted from raising their hips (e.g., following total joint replacement), has a shallow end approximately 1.3 cm ( inch) deep that slips easily under a patient. The open end of the regular pan fits just under the upper thighs, and the back of the pan fits under the patients buttocks toward the sacrum. For the fracture pan, the handle is just under the thighs, and the smaller portion is toward the buttocks.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 844

OBJ: Implement the following skills: assisting the patient in using a bedpan.

TOP: Fracture Pan KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

4. _____________ is defined by a number of signs including infrequent bowel movements, difficulty evacuating, hard stools, and inability to defecate.

ANS:

Constipation

Constipation is a symptom with a number of signs including infrequent bowel movements, difficulty evacuating, hard stools, and inability to defecate.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 842

OBJ: Describe factors that promote and impede normal bowel elimination.

TOP: Obstipation KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

5. The inability to pass a hard collection of stool is known as ______________.

ANS:

fecal impaction

Fecal impaction, the inability to pass a hard collection of stool, occurs in all age groups.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 849

OBJ: Describe factors that promote and impede normal bowel elimination.

TOP: Fecal Impaction KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

6. An ___________ is the instillation of a solution into the rectum and sigmoid colon to promote defecation by stimulating peristalsis.

ANS:

enema

An enema is the instillation of a solution into the rectum and sigmoid colon. Enemas promote defecation by stimulating peristalsis.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 852

OBJ: Describe precautions that should be followed in administering an enema.

TOP: Enema KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

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