Bowel Elimination

Question 1

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

Answer 1

Duodenum

Rationale: most nutrients are absorbed in the duodenum with the exception of certain vitamins, irons and salt (which absorb in ileum). Food is broken down in the stomach

Question 2

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

Answer 2

Ascending

Rationale: the path of digestion starts at ascending then goes to transverse, descending and finally into sigmoid

Question 3

Which of the following is not a function of the large intestine

Answer 3

Absorbing nutrients

Rationale: nutrient absorption is done in the small intestine. Absorbing water, secreting bicarbonate, and eliminating waste is in large intestine

Question 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

Answer 4

Mastication triggers the digestive system to begin peristalsis

Question 5

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

Answer 5

Grape and walnut chicken salad sandwich on while wheat bread

Rationale: a healthy diet for the bowel should include foods high in bulk forming fiber. Whole gains, fresh fruit, and fresh vegetables are excellent sources.

Question 6

A patient informs the nurse that she was using laxatives three times daily to lose weight. After stopping use of 5e laxative, the patent had difficulty with constipation and wonders if she needs tot are laxatives again. The nurse should educate the patient that

Answer 6

Long term laxative use causes the bowel to become less responsive to stimuli, and constipation may occur

Question 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

Answer 7

Raising the head of the bed

Rationale: lying in bed is an unnatural position, raising the head of the bed assist the patient into a more normal position that allows proper contraction of muscle for elimination

Question 8

Which patient is most a risk for increased peristalsis

Answer 8

A 21 year old patient with three final examinations on the same day

Rationale: stress can stimulate digestion and increase peristalsis

Question 9

A patient expresses concerns over having black stool. The fecal occult test is negative. Which response by the nurse is most appropriate

Answer 9

“ do you take iron supplements “

Rationale: certain medications and supplements, such as iron, can alter the color of stool.

Question 10

Which physiological change can cause a paralytic lieus

Answer 10

Surgery for crowns disease and anesthesia

Rationale: surgical manipulation of the bowel can cause a paralytic ileus also electrolyte imbalance, wound infection, and effects of medication

Question 11

Fecal impactions occur in which portion of the colon

Answer 11

Rectum

Rationale: a fecal impaction is a collection of hardened feces wedged in the rectum that cannot be expelled

Question 12

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

Answer 12

A 70 year old patient with stool incontinence

Rationale: a bowel elimination program is helpful for a patient with incontinence, it helps them to defecate normally

Question 13

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

Answer 13

Use the mobility device to place that patient on a bedside commode

Rationale: the best way for this is to assist the patient into a posture that is as normal as possible when defecating. Using a mobility device promotes nurse and patient safety.

Question 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

Answer 14

The patient reports eliminating a soft, formed stool

Rationale: the nurses goal is for the patient to be on opioid medication and to have normal bowel elimination. Normal stools are soft and formed

Question 15

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

Answer 15

Presence of blood in the stool

Rationale: blood in stool may indicate a problem with the surgical procedure, and the physician should be notified

Question 16

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

Answer 16

Upper endoscopy

Rationale: 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

Question 17

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

Answer 17

Donning gloves for digital removal of the stool

Rationale: 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 imbalances

Question 18

The nurse should question which order

Answer 18

A kayexalate enema for a patient with hypokalemia

Rationale: kayexalate binds to hell 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 imbalance. Hypertonic solutions are intended for patients who cannot handle lard fluid volume and are contraindicated for dehydration patients.

Question 19

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

Answer 19

Reporting any abnormal findings to the provider

Rationale: abnormal findings such as a positive test should be reported to the provider.

Question 20

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

Answer 20

Encourage the patient to increase fluids to flush out the barium. Barium swallow is a noninvasive procedure for which no trauma would produce blood or mucus or increase aspiration risk

Question 21

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

Answer 21

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

Rationale: 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 coral recumbent posting will allow the nurse to continue to administer the enema.

Question 22

A nurse is educating a patient on how to irrigate am ostomy bag. Which statement by the patient indicated the need for further instruction

Answer 22

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

Rationale: enema applicators should never be used in the stoma because they can cause damage.

Question 23

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

Answer 23

Salem sump

Rationale: the Salem sump has the width and functionality needed to both feed and suction, and its ideal for a bowel obstruction. Bowel obstruction causes a back up into the gastric area; a nasogastric tube may be inserted to decompress secretions and gasses from the GI tract

Question 24

A patient had an illeostomy surgically placed 2 days ago. Which diet would the nurse recommend to the patient to ease the transition of the new ostomy

Answer 24

Turkey meatloaf with white rice and apple juice

Rationale: the patient should consume easy to digest low fiber foods such as poultry, rice and noodles and strained fruit juices

Question 25

A nurse is pouching an ostomy on a patient with an ileostomy. Which action by the nurse is the most appropriate

Answer 25

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

Question 26

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

Answer 26

Before eating a meal, when the patient is comfortable

Question 27

The nurse administers a cathartic to a patient. The nurse determined that the cathartic has had

Answer 27

A bowel movement Rationale: a cathartic is a laxative that stimulates a bowel movement

Question 28

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

Answer 28

Apply a skin protective lotion after perineal care

Question 29

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

Answer 29

Lubricating the nares with water soluble lubricant

Question 30

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

Answer 30

“If I get a positive result, I have gastrointestinal bleeding” Rationale: a positive result does not mean GI bleeding; it could be false positive from consuming red meat or raw vegetables.

Question 31

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

Answer 31

Falls from attempts to reach the bathroom Rationale: 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 patient should clear the path and reinforce use of the call light

Question 32

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

Answer 32

Hypoactive bowel sounds Rationale: no bowel movement indicates hypo motility of the GI tract. Assessment findings would indicate hypoactive bowel sounds, a firm distended abdomen, and pain or discomfort upon palpation(using hands)

Question 33

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

Answer 33

Decreased serum bicarbonate Rationale: patients with chronic diarrhea are dehydrated with decrease blood pressure, loss of electrolytes, nutrients, fluids which decreases energy levels.

Question 34

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

Answer 34

Stoma is purple Rationale: 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.

Question 35

A patient had constipation and hypernatremia( high concentration of sodium in blood). The nurse prepares to administer which type of enema

Answer 35

Tap water enema Rationale: tap water would draw fluid into the system and would help flush out excess sodium.

Question 36

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

Answer 36

Blood that can not be seen Rationale: fecal occult blood tests are used to test for blood that may be present in stool that cannot be seen by the makes eye.

Question 37

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

Answer 37

Side lying sims position

Question 38

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

Answer 38

Bowel sounds Rationale: the nurse does want to hear the presence of bowel sounds, absent bowel sounds may indicate complication from surgery