Chapter 46: Bowel Elimination Nursing School Test Banks

Test Bank

MULTIPLE CHOICE

1. The nurse knows that most nutrients are absorbed in which portion of the digestive tract?

a.

Stomach

b.

Duodenum

c.

Ileum

d.

Cecum

ANS: B

Most nutrients are absorbed in the duodenum with the exception of certain vitamins, iron, and salt (which are absorbed in the ileum). Food is broken down in the stomach. The cecum is the beginning of the large intestine.

DIF: Remember REF: 1088

OBJ: Discuss the role of gastrointestinal organs in digestion and elimination.

TOP: Implementation

MSC: Physiological Integrity | Physiological Adaptation | Alterations in Body Systems | Bowel Elimination

2. The nurse would expect the least formed stool to be present in which portion of the digestive tract?

a.

Ascending

b.

Descending

c.

Transverse

d.

Sigmoid

ANS: A

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 would be in the ascending.

DIF: Remember REF: 1088

OBJ: Explain the physiological aspects of normal defecation. TOP: Assessment

MSC: Physiological Integrity | Physiological Adaptation | Alterations in Body Systems | Bowel Elimination

3. Which of the following is not a function of the large intestine?

a.

Absorbing nutrients

b.

Absorbing water

c.

Secreting bicarbonate

d.

Eliminating waste

ANS: A

Nutrient absorption is done in the small intestine. The other options are all functions of the large intestine.

DIF: Remember REF: 1088 OBJ: Describe three functions of the large intestine.

TOP: Implementation

MSC: Physiological Integrity | Physiological Adaptation | Alterations in Body Systems | Bowel Elimination

4. The nurse is caring for a patient who is confined to the bed. The nurse asks the patient if he needs to have a bowel movement 30 minutes after eating a meal because

a.

The digested food needs to make room for recently ingested food.

b.

Mastication triggers the digestive system to begin peristalsis.

c.

The smell of bowel elimination in the room would deter the patient from eating.

d.

More ancillary staff members are available after meal times.

ANS: B

Peristalsis occurs only a few times a day; the strongest peristaltic waves are triggered by mastication of the meal. The intestine can hold a great deal of food. A patients voiding schedule should not be based on the staffs convenience.

DIF: Understand REF: 1102

OBJ: List nursing interventions included in bowel training. TOP: Implementation

MSC: Physiological Integrity | Physiological Adaptation | Alterations in Body Systems | Bowel Elimination

5. A nurse is assisting a patient in making dietary choices that promote healthy bowel elimination. Which menu option should the nurse recommend?

a.

Grape and walnut chicken salad sandwich on whole wheat bread

b.

Broccoli and cheese soup with potato bread

c.

Dinner salad topped with hard-boiled eggs, cheese, and fat-free dressing

d.

Turkey and mashed potatoes with brown gravy

ANS: A

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 REF: 1089

OBJ: List nursing interventions that promote normal elimination.

TOP: Implementation

MSC: Physiological Integrity | Physiological Adaptation | Alterations in Body Systems | Bowel Elimination

6. A patient informs the nurse that she was using laxatives three times daily to lose weight. After stopping use of the laxative, the patient had difficulty with constipation and wonders if she needs to take laxatives again. The nurse educates the patient that

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.

Natural laxatives such as mineral oil are safer than chemical laxatives for relieving constipation.

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

Long-term laxative use can lead to constipation. Increasing fluid and fiber intake can help with this problem. Laxatives do not cause scarring. Natural laxatives like mineral oil come with their own set of risks, such as inability to absorb fat-soluble vitamins. Even if malnourished, the body will produce waste if substance is consumed.

DIF: Understand REF: 1091| 1106

OBJ: Use critical thinking in the provision of care to patients with alterations in bowel elimination.

TOP: Implementation

MSC: Physiological Integrity | Physiological Adaptation | Alterations in Body Systems | Bowel Elimination

7. A patient with a hip fracture is having difficulty defecating into a bed pan while lying in bed. Which action by the nurse would assist the patient in having a successful bowel movement?

a.

Administering laxatives to the patient

b.

Raising the head of the bed

c.

Preparing to administer a barium enema

d.

Withholding narcotic pain medication

ANS: B

Lying in bed is an unnatural position; raising the head of the bed assists the patient into a more normal position 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 REF: 1090

OBJ: Discuss psychological and physiological factors that influence the elimination process.

TOP: Implementation

MSC: Physiological Integrity | Physiological Adaptation | Alterations in Body Systems | Bowel Elimination

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 patient with three final examinations on the same day

c.

A 40-year-old woman with major depressive disorder

d.

An 80-year-old man in an assisted-living environment

ANS: B

Stress can stimulate digestion and increase peristalsis. Ignoring the urge to defecate, depression, and age-related changes of the elderly are causes of constipation.

DIF: Understand REF: 1090

OBJ: Describe common physiological alterations in elimination.

TOP: Implementation

MSC: Physiological Integrity | Physiological Adaptation | Alterations in Body Systems | Bowel Elimination

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.

Do you take iron supplements?

c.

You should schedule a colonoscopy as soon as possible.

d.

Sometimes severe stress can alter stool color.

ANS: B

Certain medications and supplements, such as iron, can alter the color of stool. The fecal occult test takes three separate samples over a period 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 nurses initial priority. Stress alters GI motility and stool consistency, not color.

DIF: Apply REF: 1091

OBJ: Use critical thinking in the provision of care to patients with alterations in bowel elimination.

TOP: Implementation

MSC: Physiological Integrity | Physiological Adaptation | Alterations in Body Systems | Bowel Elimination

10. Which physiological change can cause a paralytic ileus?

a.

Chronic cathartic abuse

b.

Surgery for Crohns disease and anesthesia

c.

Suppression of hydrochloric acid from medication

d.

Fecal impaction

ANS: B

Surgical manipulation of the bowel can cause a paralytic ileus. The other options are incorrect.

DIF: Remember REF: 1090-1091

OBJ: Describe common physiological alterations in elimination.

TOP: Implementation

MSC: Physiological Integrity | Physiological Adaptation | Alterations in Body Systems | Bowel Elimination

11. Fecal impactions occur in which portion of the colon?

a.

Ascending

b.

Descending

c.

Transverse

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 hardened mass.

DIF: Remember REF: 1091-1092 OBJ: Assess a patients elimination pattern.

TOP: Assessment

MSC: Physiological Integrity | Physiological Adaptation | Alterations in Body Systems | Bowel Elimination

12. The nurse provides knows that a bowel elimination schedule would be most beneficial in the plan of care for which patient?

a.

A 40-year-old patient with an ileostomy

b.

A 25-year-old patient with Crohns disease

c.

A 30-year-old patient with C. difficile

d.

A 70-year-old patient with stool incontinence

ANS: D

A bowel elimination program is helpful for a patient with incontinence. It helps the person who still has neuromuscular control defecate normally. An ileostomy, Crohns disease, and C. difficile all relate to uncontrollable bowel movements, for which no method can be used to set up a schedule of elimination.

DIF: Evaluate REF: 1110

OBJ: List nursing interventions included in bowel training. TOP: Planning

MSC: Physiological Integrity | Physiological Adaptation | Alterations in Body Systems

13. Which nursing intervention is most effective in promoting normal defecation for a patient who has muscle weakness in the legs that prevents ambulation?

a.

Elevate the head of the bed 45 degrees 60 minutes after breakfast.

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.

Administer a soap suds enema every 2 hours.

ANS: B

The best way to promote normal defecation is to assist the patient into a posture that is as normal as possible while defecating. Using a mobility device promotes nurse and patient safety. Elevating the head of the bed would be appropriate if the patient were to void with a bed pan. However, the patients condition does not require use of a bed pan. Giving the patient a pillow may reduce discomfort, but this is not the best way to promote defecation. A soaps suds enema is indicated for a patient who needs assistance to stimulate peristalsis. It promotes non-natural defecation.

DIF: Apply REF: 1104

OBJ: List nursing interventions included in bowel training. TOP: Implementation

MSC: Physiological Integrity | Physiological Adaptation | Alterations in Body Systems

14. The nurse is devising a plan of care for a patient with the nursing diagnosis of Constipation related to opioid use. Which of the following outcomes would 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 patients lower left quadrant is tender to the touch.

d.

The nurse hears bowel sounds present in all four quadrants.

ANS: A

The nurses goal is for the patient to be on 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 further address bowel elimination. Present bowel sounds indicate that the bowels are moving; however, they are not an indication of defecation.

DIF: Apply REF: 1091| 1101-1102

OBJ: List nursing diagnoses related to alterations in elimination.

TOP: Evaluation

MSC: Physiological Integrity | Physiological Adaptation | Alterations in Body Systems

15. The nurse is emptying an ileostomy pouch for a patient. Which assessment finding would the nurse report immediately?

a.

Liquid consistency of stool

b.

Presence of blood in the stool

c.

Noxious odor from the stool

d.

Continuous output from the stoma

ANS: B

Blood in the stool may indicate a problem with the surgical procedure, and the physician should be notified. All other options are expected findings for an ileostomy.

DIF: Apply REF: 1096-1097| 1100

OBJ: Use critical thinking in the provision of care to patients with alterations in bowel elimination.

TOP: Assessment

MSC: Physiological Integrity | Physiological Adaptation | Alterations in Body Systems

16. The nurse would anticipate which diagnostic examination for a patient with black tarry stools?

a.

Ultrasound

b.

Barium enema

c.

Upper endoscopy

d.

Flexible sigmoidoscopy

ANS: C

Black tarry stools are an indication of ulceration or bleeding in the upper portion of the GI tract; upper endoscopy would allow visualization of the bleeding. No other option would allow upper GI visualization.

DIF: Understand REF: 1190

OBJ: Use critical thinking in the provision of care to patients with alterations in bowel elimination.

TOP: Planning

MSC: Physiological Integrity | Physiological Adaptation | Alterations in Body Systems

17. The nurse has attempted to administer a tap water enema for a patient with fecal impaction with no success. What is the next priority nursing action?

a.

Preparing the patient for a second tap water enema

b.

Donning gloves for digital removal of the 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 occasionally 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 imbalance. Positioning the patient on the left side does not promote defecation. A rectal tube is indicated for a patient with liquid stool incontinence but would not be applicable or effective for this patient.

DIF: Apply REF: 1107

OBJ: Use critical thinking in the provision of care to patients with alterations in bowel elimination.

TOP: Implementation

MSC: Physiological Integrity | Physiological Adaptation | Alterations in Body Systems

18. The nurse should question which order?

a.

A normal saline enema to be repeated every 4 hours until stool is produced

b.

A hypertonic solution enema with a patient with fluid volume excess

c.

A Kayexalate enema for a patient with hypokalemia

d.

An oil retention enema for a patient using mineral oil laxatives

ANS: C

Kayexalate binds to and helps excrete potassium, so it would be contraindicated in patients who are hypokalemic (have low potassium). Normal saline enemas can be repeated without risk of fluid or electrolyte imbalance. Hypertonic solutions are intended for patients who cannot handle large fluid volume and are contraindicated for dehydrated patients. Because mineral oil laxatives and an oil retention enema have the same intended effect of lubricating the colon and rectum, an oil retention enema is not needed.

DIF: Apply REF: 1106-1107

OBJ: Use critical thinking in the provision of care to patients with alterations in bowel elimination.

TOP: Planning

MSC: Physiological Integrity | Physiological Adaptation | Alterations in Body Systems

19. The nurse is preparing to perform a fecal occult blood test. The nurse plans to properly perform the examination by

a.

Applying liberal amounts of stool to the guaiac paper.

b.

Testing the quality control section before collecting the specimen section.

c.

Reporting any abnormal findings to the provider.

d.

Applying sterile disposable gloves.

ANS: C

Abnormal findings such as a positive test 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 quality control section should be developed after it is determined whether the sample is positive or negative.

DIF: Understand REF: 1099

OBJ: Describe nursing implications for common diagnostic examinations of the gastrointestinal tract. TOP: Planning

MSC: Physiological Integrity | Physiological Adaptation | Alterations in Body Systems

20. A nurse is preparing a patient for a magnetic resonance imaging scan. Which nursing action is most important?

a.

Ensuring that the patient does not eat or drink 2 hours before the examination

b.

Removing all of the patients metallic jewelry

c.

Administering a colon cleansing product 12 hours before the examination

d.

Obtaining an order for a pain medication before the test is performed

ANS: B

No jewelry or metal products should be in the same room as an MRI machine because of the high-power magnet 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 REF: 1101

OBJ: Describe nursing implications for common diagnostic examinations of the gastrointestinal tract. TOP: Planning

MSC: Physiological Integrity | Physiological Adaptation | Alterations in Body Systems

21. After a patient returns from a barium swallow, the nurses priority is to

a.

Encourage the patient to increase fluids to flush out the barium.

b.

Monitor stools closely for bright red blood or mucus, which indicates trauma from the procedure.

c.

Inform the patient that his bowel movements are radioactive, and that he should be sure to flush the toilet three times.

d.

Thicken all patient drinks to prevent aspiration.

ANS: A

Encourage the patient to increase fluid intake to flush and remove excess barium from the body. Barium swallow is a noninvasive procedure for which no trauma would produce blood or mucus or increase aspiration risk. Barium is not a radioactive substance, so multiple flushes are not needed.

DIF: Apply REF: 1101

OBJ: Describe nursing implications for common diagnostic examinations of the gastrointestinal tract. TOP: Planning

MSC: Physiological Integrity | Physiological Adaptation | Alterations in Body Systems

22. While a cleansing enema is administered to an 80-year-old patient, the patient expresses the urge to defecate. What is the next priority nursing action?

a.

Positioning the patient in the dorsal recumbent position with a bed pan

b.

Assisting the patient to the bedside commode

c.

Stopping the enema cleansing and rolling the patient into right-lying Sims position

d.

Inserting a rectal plug to contain the enema solution

ANS: A

Patients with poor sphincter control may not be able to hold in all of an enema solution. Positioning the patient on a bed pan in dorsal recumbent position will allow the nurse to continue to administer the enema. Having the patient get up to toilet is unsafe because the rectal tube can damage the mucosal lining. The purpose of the enema is to promote defecation; stopping it early may inhibit its effectiveness. Use of a rectal plug to contain the solution is inappropriate.

DIF: Apply REF: 1107

OBJ: List nursing interventions included in bowel training. TOP: Implementation

MSC: Physiological Integrity | Physiological Adaptation | Alterations in Body Systems

23. A nurse is educating a patient on how to irrigate an ostomy bag. Which statement by the patient indicates the need for further instruction?

a.

I can use a fleet enema to save money because it contains the same irrigation solution.

b.

Sitting on the toilet lets the irrigation sleeve eliminate into the bowl.

c.

I should never attempt to reach into my stoma to remove fecal material.

d.

Using warm tap water will reduce cramping and discomfort during the procedure.

ANS: A

Enema applicators should never be used in the stoma because they can cause damage. A special coned irrigation device is used for ostomies. Irrigating a stoma into the toilet is an effective management technique. Fingers and other objects should not be placed into the stoma because they may cause trauma to the intestinal wall. Warm tap water will reduce cramping during irrigation.

DIF: Apply REF: 1109

OBJ: Discuss nursing care measures required for patients with a bowel diversion.

TOP: Implementation

MSC: Physiological Integrity | Physiological Adaptation | Alterations in Body Systems

24. A patient is diagnosed with a bowel obstruction. The nurse chooses which type of tube for gastric decompression?

a.

Salem sump

b.

Dobhoff

c.

Sengstaken-Blakemore

d.

Small bore

ANS: A

A bowel obstruction causes a backup into the gastric area; a nasogastric tube may be inserted to decompress secretions and gases from the gastrointestinal tract. The Salem sump has the width and functionality needed to both feed and suction, and it is ideal for a bowel obstruction. A Dobhoff tube is used for instillation of feedings. A Sengstaken-Blakemore tube is used to compress stomach contents to prevent hemorrhage. A small bore is intended for nutritional feedings only and does not have suction capacity.

DIF: Apply REF: 1108

OBJ: Use critical thinking in the provision of care to patients with alterations in bowel elimination.

TOP: Implementation

MSC: Physiological Integrity | Physiological Adaptation | Alterations in Body Systems | Bowel Elimination

25. A patient had an ileostomy surgically placed 2 days ago. Which diet would the nurse recommend to the patient 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 stir fried vegetables and iced tea

c.

Turkey meatloaf with white rice and apple juice

d.

Fish sticks with macaroni and cheese and soda

ANS: C

During the first week or so after ostomy placement, the patient should consume easy-to-digest low-fiber foods such as poultry, rice and noodles, and strained fruit juices. Fried foods can irritate digestion and can cause blockage. Foods high in fiber will be useful later in the recovery process but can cause blockage if the GI tract is not accustomed to digesting with an ileostomy.

DIF: Apply REF: 1110

OBJ: Discuss nursing care measures required for patients with a bowel diversion.

TOP: Implementation

MSC: Physiological Integrity | Physiological Adaptation | Alterations in Body Systems | Bowel Elimination

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.

Selecting a pouch that is able to hold excess output to reduce the frequency of pouch emptying

c.

Thoroughly scrubbing the skin around the stoma to remove excess stool and adhesive

d.

Measuring the correct size for the barrier device while leaving a 1/8-inch space around the stoma

ANS: B

Selecting a pouch that holds a large volume of output will decrease the frequency of emptying the pouch and may ease patient anxiety about pouch overflow. The barrier device should be changed every few 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. Approximately 1/16 of an inch is present between the barrier device and the stoma. Excess space allows fecal matter to have prolonged exposure to skin, resulting in skin breakdown.

DIF: Apply REF: 1109-1110

OBJ: Discuss nursing care measures required for patients with a bowel diversion.

TOP: Implementation

MSC: Physiological Integrity | Physiological Adaptation | Alterations in Body Systems | Bowel Elimination

27. The nurse knows that the ideal time to change an ostomy pouch is

a.

Before eating a meal, when the patient is comfortable.

b.

When the patient feels that he needs to have a bowel movement.

c.

When ordered in the patients chart.

d.

After the patient has ambulated the length of the hallway.

ANS: A

The nurse wants to change the ostomy appliance when as little output as necessary ensures a smooth procedure. Patients with ostomies do not feel the urge to defecate because the sensory portion of the anus is not stimulated. Changing the ostomy pouch is a nursing judgment decision. After a patient ambulates, stool output is increased.

DIF: Understand REF: 1109-1110

OBJ: Discuss nursing care measures required for patients with a bowel diversion.

TOP: Assessment

MSC: Physiological Integrity | Physiological Adaptation | Alterations in Body Systems | Bowel Elimination

28. The nurse administers a cathartic to a patient. The nurse determines that the cathartic has had a therapeutic effect when the patient

a.

Has a decreased level of anxiety.

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.

DIF: Apply REF: 1106

OBJ: Use critical thinking in the provision of care to patients with alterations in bowel elimination.

TOP: Planning

MSC: Physiological Integrity | Physiological Adaptation | Alterations in Body Systems

29. An older adults perineal skin appears to be dry and thin with mild excoriation. When providing hygiene after a bowel movement, the nurse should

a.

Thoroughly scrub the skin with a wash cloth and hypoallergenic soap.

b.

Apply a skin protective lotion after perineal care.

c.

Tape an occlusive moisture barrier pad to the patients skin.

d.

Massage the skin with deep kneading pressure.

ANS: B

Proper skin care and perineal cleaning require that the nurse gently clean the skin and apply a moistening barrier cream. Tape and occlusive dressings can damage skin. Excessive pressure and force are inappropriate and may cause skin breakdown.

DIF: Apply REF: 1111

OBJ: List nursing interventions that promote normal elimination.

TOP: Planning

MSC: Physiological Integrity | Physiological Adaptation | Alterations in Body Systems

30. Which nursing action best reduces risk of excoriation to the mucosal lining of the nose from a nasogastric tube?

a.

Lubricating the nares with water-soluble lubricant

b.

Applying a small ice bag to the nose for 5 minutes every 4 hours

c.

Instilling Xylocaine into the nares once a shift

d.

Changing the tape holding the tube in place once a shift

ANS: A

The tube constantly irritates the nasal mucosa, increasing the risk of excoriation. Frequent lubrication with a water-soluble lubricant decreases the likelihood of excoriation. Ice is not applied to the nose. Ice may be applied externally to the throat if the patient reports a sore throat. Xylocaine requires a physician order and is used to treat sore throat, not nasal mucosal excoriation. Changing the tape should be done daily, not every shift.

DIF: Evaluate REF: 1108

OBJ: List nursing interventions that promote normal elimination.

TOP: Implementation

MSC: Physiological Integrity | Physiological Adaptation | Alterations in Body Systems

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 positive result, I have gastrointestinal bleeding.

b.

I should not eat red meat before my examination.

c.

I should schedule to perform the examination when I am not menstruating.

d.

I will need to perform this test three times if I have a positive result.

ANS: A

A positive result does not mean GI bleeding; it could be a false positive from consuming red meat, some raw vegetables, or NSAIDs. Proper patient education is important for viable results. The patient needs to avoid certain foods to rule out a false positive. If the test is positive, the patient will need to repeat the test at least three times. Menses and hemorrhoids can also lead to false positives.

DIF: Apply REF: 1099-1100

OBJ: Describe nursing implications for common diagnostic examinations of the gastrointestinal tract. TOP: Evaluation

MSC: Physiological Integrity | Physiological Adaptation | Alterations in Body Systems

32. A nurse is caring for an older adult patient with fecal incontinence due to cathartic use. The nurse is most concerned about which complication that has the greatest risk for severe injury?

a.

Rectal skin breakdown

b.

Contamination of existing wounds

c.

Falls from attempts to reach the bathroom

d.

Cross-contamination into the upper GI tract

ANS: C

The nurse is most concerned about the worst injury the patient could receive, which involves falling while attempting to get to the bathroom. To reduce injury, the nurse should clear the path and reinforce use of the call light. The question is asking for the greatest risk of injury, not the most frequent occurrence or the event most likely to occur.

DIF: Apply REF: 1107

OBJ: Use critical thinking in the provision of care to patients with alterations in bowel elimination.

TOP: Planning

MSC: Physiological Integrity | Physiological Adaptation | Alterations in Body Systems

33. The nurse is caring for a patient with Clostridium difficile. Which of the following nursing actions will have the greatest impact in preventing the spread of bacteria?

a.

Monthly in-services about contact precautions

b.

Placing all contaminated items in biohazard bags

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. Monthly in-services place emphasis on education, not on action. Biohazard bags are appropriate but cannot be used on every item that C. difficilecomes in contact with, such as a human. Mandatory cultures are expensive and unnecessary and would not prevent the spread of bacteria.

DIF: Apply REF: 1092

OBJ: Discuss psychological and physiological factors that influence the elimination process.

TOP: Planning

MSC: Physiological Integrity | Physiological Adaptation | Alterations in Body Systems

34. A nurse is performing an assessment on a patient who has not had a bowel movement in 3 days. The nurse would expect which other assessment finding?

a.

Hypoactive bowel sounds

b.

Jaundice in sclera

c.

Decreased skin turgor

d.

Soft tender abdomen

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.

DIF: Apply REF: 1091 OBJ: Assess a patients elimination pattern.

TOP: Assessment

MSC: Physiological Integrity | Physiological Adaptation | Alterations in Body Systems

35. A nurse is caring for a patient who has had diarrhea for the past week. Which additional assessment finding would the nurse expect?

a.

Increased energy levels

b.

Distended abdomen

c.

Decreased serum bicarbonate

d.

Increased blood pressure

ANS: C

Chronic diarrhea can result in metabolic acidosis, which is diagnostic of low serum bicarbonate. Patients with chronic diarrhea are dehydrated with decreased blood pressure. Diarrhea also causes loss of electrolytes, nutrients, and fluid, which decreases energy levels. A distended abdomen would indicate constipation.

DIF: Apply REF: 1092 OBJ: Assess a patients elimination pattern.

TOP: Planning

MSC: Physiological Integrity | Physiological Adaptation | Alterations in Body Systems

36. The nurse is caring for a patient who had a colostomy placed yesterday. The nurse should report which assessment finding immediately?

a.

Stoma is protruding from the abdomen.

b.

Stoma is moist.

c.

Stool is discharging from the stoma.

d.

Stoma is purple.

ANS: D

A purple stoma may indicate strangulation 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. Stool is an expected outcome of stoma placement.

DIF: Apply REF: 1097| 1110

OBJ: Discuss nursing care measures required for patients with a bowel diversion.

TOP: Assessment

MSC: Physiological Integrity | Physiological Adaptation | Alterations in Body Systems

37. A patient has constipation and hypernatremia. The nurse prepares to administer which type of enema?

a.

Oil retention

b.

Carminative

c.

Saline

d.

Tap water

ANS: D

Tap water enema would draw fluid into the system and would help flush out excess sodium. Oil retention would not address sodium problems. Carminative enemas are used to provide relief from distention caused by gas. A saline enema would worsen hypernatremia.

DIF: Apply REF: 1107

OBJ: List nursing interventions that promote normal elimination.

TOP: Implementation

MSC: Physiological Integrity | Physiological Adaptation | Alterations in Body Systems

38. A guaiac test has been ordered. The nurse knows that this is a test for

a.

Bright red blood.

b.

Dark black blood.

c.

Blood that contains mucus.

d.

Blood that cannot be seen.

ANS: D

Fecal occult blood tests are used to test for blood that may be present in stool that cannot be seen by the naked eye. This is usually indicative of a GI bleed. All other options are incorrect.

DIF: Understand REF: 1099

OBJ: Describe nursing implications for common diagnostic examinations of the gastrointestinal tract. TOP: Assessment

MSC: Physiological Integrity | Physiological Adaptation | Alterations in Body Systems

39. The nurse should place the patient in which position when preparing to administer an enema?

a.

Left Sims position

b.

Fowlers

c.

Supine

d.

Semi-Fowlers

ANS: A

Side-lying Sims position allows the enema solution to flow downward by gravity along the natural curve of the sigmoid colon. This helps to improve retention of the enema. Administering an enema in a sitting position may allow the curved rectal tube to scrape the rectal wall.

DIF: Remember REF: 1107| 1113

OBJ: List nursing interventions that promote normal elimination.

TOP: Implementation

MSC: Physiological Integrity | Physiological Adaptation | Alterations in Body Systems

40. The nurse is assessing a patient 2 hours after a colonoscopy. Based on the procedure done, what focused assessment will the nurse include?

a.

Bowel sounds

b.

Presence of flatulence

c.

Bowel movements

d.

Nausea

ANS: A

The nurse does want to hear the presence of bowel sounds; absent bowel sounds may indicate a complication from the surgery. Bowel movements and flatulence are not expected in the hours after surgery. The nurse does want to hear the presence of bowel movements. Nausea is not a problem following colonoscopy.

DIF: Apply REF: 1097| 1101

OBJ: Describe nursing implications for common diagnostic examinations of the gastrointestinal tract. TOP: Assessment

MSC: Physiological Integrity | Physiological Adaptation | Alterations in Body Systems

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