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Flashcards in Deck 1 - Bowel Elimination Deck (42)
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1

The nurse is teaching a health class about the gastrointestinal tract. The nurse will explain that which portion of the digestive tract absorbs most of the nutrients?
a. Ileum
b. Cecum
c. Stomach
d. Duodenum

d. Duodenum

Rationale:

The duodenum and jejunum absorb most nutrients and electrolytes in the small intestine. The ileum absorbs certain vitamins, iron, and bile salts. Food is broken down in the stomach. The cecum is the beginning of the large intestine.

2

The nurse is caring for patients with ostomies. In which ostomy location will the nurse expect very liquid stool to be present?
a. Sigmoid
b. Transverse
c. Ascending
d. Descending

c. Ascending

Rationale:

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 (very liquid) would be in the ascending.

3

A nurse is teaching a patient about the large intestine in elimination. In which order will the nurse list the structures, starting with the first portion?
a. Cecum, ascending, transverse, descending, sigmoid, and rectum
b. Ascending, transverse, descending, sigmoid, rectum, and cecum
c. Cecum, sigmoid, ascending, transverse, descending, and rectum
d. Ascending, transverse, descending, rectum, sigmoid, and cecum

a. Cecum, ascending, transverse, descending, sigmoid, and rectum

Rationale:

The large intestine is divided into the cecum, ascending colon, transverse colon, descending colon, sigmoid colon, and rectum. The large intestine is the primary organ of bowel elimination.

4

The nurse is planning care for a group of patients. Which task will the nurse assign to the nursing assistive personnel (NAP)?
a. Performing the first postoperative pouch change
b. Maintaining a nasogastric tube
c. Administering an enema
d. Digitally removing stool

c. Administering an enema

Rationale:

The skill of administering an enema can be delegated to an NAP. The skill of inserting and maintaining a nasogastric (NG) tube cannot be delegated to an NAP. The nurse should do the first postoperative pouch change. Digitally removing stool cannot be delegated to nursing assistive personnel.

5

A nurse is assisting a patient in making dietary choices that promote healthy bowel elimination. Which menu option should the nurse recommend?
a. Broccoli and cheese soup with potato bread
b. Turkey and mashed potatoes with brown gravy
c. Grape and walnut chicken salad sandwich on whole wheat bread
d. Dinner salad topped with hard-boiled eggs, cheese, and fat-free dressing

c. Grape and walnut chicken salad sandwich on whole wheat bread

Rationale:

Grapes and whole wheat bread are high fiber and should be chosen. Cheese, eggs, potato bread, and mashed potatoes do not contain as much fiber as whole wheat bread. 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.

6

A patient is using laxatives three times daily to lose weight. After stopping laxative use, the patient has difficulty with constipation and wonders if laxatives should be taken again. Which information will the nurse share with the patient?
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. Long-term use of emollient laxatives is effective for treatment of chronic constipation and may be useful in certain situations.
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.

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

Rationale:

Teach patients about the potential harmful effects of overuse of laxatives, such as impaired bowel motility and decreased response to sensory stimulus. Make sure the patient understands that laxatives are not to be used long term for maintenance of bowel function. Increasing fluid and fiber intake can help with this problem. Laxatives do not cause scarring. Even if malnourished, the body will produce waste if any substance is consumed.

7

A patient with a hip fracture is having difficulty defecating into a bedpan while lying in bed. Which action by the nurse will assist the patient in having a successful bowel movement?
a. Preparing to administer a barium enema
b. Withholding narcotic pain medication
c. Administering laxatives to the patient
d. Raising the head of the bed

d. Raising the head of the bed

Rationale:

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.

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 female with three final examinations on the same day
c. A 40-year-old female with major depressive disorder
d. An 80-year-old male in an assisted-living environment

b. A 21-year-old female with three final examinations on the same day

Rationale:

Stress can stimulate digestion and increase peristalsis, resulting in diarrhea; three finals on the same day is stressful. Ignoring the urge to defecate, depression, and age-related changes of the older adult (80-year-old man) are causes of constipation, which is from slowed peristalsis.

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. “You should schedule a colonoscopy as soon as possible.”
c. “Are you under a lot of stress?”
d. “Do you take iron supplements?”

d. “Do you take iron supplements?”

Rationale:

Certain medications and supplements, such as iron, can alter the color of stool (black or tarry). Since the fecal occult test is negative, bleeding is not occurring. 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 nurse’s initial priority. Stress alters GI motility and stool consistency, not color.

10

Which patient will the nurse assess most closely for an ileus?
a. A patient with a fecal impaction
b. A patient with chronic cathartic abuse
c. A patient with surgery for bowel disease and anesthesia
d. A patient with suppression of hydrochloric acid from medication

c. A patient with surgery for bowel disease and anesthesia

Rationale:

Any surgery that involves direct manipulation of the bowel temporarily stops peristalsis. Anesthesia can also cause cessation of peristalsis. This condition, called an ileus, usually lasts about 24 to 48 hours. Fecal impaction, cathartic abuse, and medication to suppress hydrochloric acid will have bowel sounds, but they may be hypoactive or hyperactive.

11

A patient has a fecal impaction. Which portion of the colon will the nurse assess?
a. Descending
b. Transverse
c. Ascending
d. Rectum

d. Rectum

Rationale:

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.

12

The nurse is managing bowel training for a patient. To which patient is the nurse most likely providing care?
a. A 25-year-old patient with diarrhea
b. A 30-year-old patient with Clostridium difficile
c. A 40-year-old patient with an ileostomy
d. A 70-year-old patient with stool incontinence

d. A 70-year-old patient with stool incontinence

Rationale:

The patient with chronic constipation or fecal incontinence secondary to cognitive impairment may benefit from bowel training, also called habit training. An ileostomy, diarrhea, and C. difficile all relate to uncontrollable bowel movements, for which no method can be used to set up a schedule of elimination.

13

Which nursing intervention is most effective in promoting normal defecation for a patient who has muscle weakness in the legs?
a. Administer a soapsuds enema every 2 hours.
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. Elevate the head of the bed 20 degrees 60 minutes after breakfast while on bedpan.

b. Use a mobility device to place the patient on a bedside commode.

Rationale:

The best way to promote normal defecation is to assist the patient into a posture that is as normal as possible for defecation. Using a mobility device promotes nurse and patient safety. Elevating the head of the bed is appropriate but is not the most effective; closer to 30 to 45 degrees is the proper position for the patient on a bedpan, and the patient is not on bed rest so a bedside commode is the best choice. Giving the patient a pillow may reduce discomfort, but this is not the best way to promote defecation. A soapsuds enema is indicated for a patient who needs assistance to stimulate peristalsis. It promotes non-natural defecation.

14

The nurse is devising a plan of care for a patient with the nursing diagnosis of Constipation related to opioid use. Which outcome will 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 patient’s lower left quadrant is tender to the touch.
d. The nurse hears bowel sounds in all four quadrants.

a. The patient reports eliminating a soft, formed stool.

Rationale:

The nurse’s goal is for the patient to take 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 indicate success. Bowel sounds indicate that the bowels are moving; however, they are not an indication of defecation.

15

The nurse is emptying an ileostomy pouch for a patient. Which assessment finding will the nurse report immediately?
a. Liquid consistency of stool
b. Presence of blood in the stool
c. Malodorous stool
d. Continuous output from the stoma

b. Presence of blood in the stool

Rationale:

Blood in the stool indicates a problem, and the health care provider should be notified. All other options are expected findings for an ileostomy. The stool should be liquid, there should be an odor, and the output should be continuous.

16

The nurse will anticipate which diagnostic examination for a patient with black tarry stools?
a. Ultrasound
b. Barium enema
c. Endoscopy
d. Anorectal manometry

c. Endoscopy

Rationale:

Black tarry stools are an indication of bleeding in the GI tract; endoscopy would allow visualization of the bleeding. No other option (ultrasound, barium enema, and anorectal manometry) would allow GI visualization.

17

The nurse has attempted to administer a tap water enema for a patient with fecal impaction with no success. The fecal mass is too large for the patient to pass voluntarily. Which is the nextpriority nursing action?
a. Preparing the patient for a second tap water enema
b. Obtaining an order for digital removal of stool
c. Positioning the patient on the left side
d. Inserting a rectal tube

b. Obtaining an order for digital removal of stool

Rationale:

When enemas are not successful, digital removal of the stool may be necessary 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 or flatus but would not be applicable or effective for this patient.

18

A nurse is checking orders. Which order should the nurse question?
a. A normal saline enema to be repeated every 4 hours until stool is produced
b. A hypertonic solution enema for a patient with fluid volume excess
c. A Kayexalate enema for a patient with severe hypokalemia
d. An oil retention enema for a patient with constipation

c. A Kayexalate enema for a patient with severe hypokalemia

Rationale:

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. Oil retention enemas lubricate the feces in the rectum and colon and are used for constipation.

19

The nurse is performing a fecal occult blood test. Which action should the nurse take?
a. Test the quality control section before testing the stool specimens.
b. Apply liberal amounts of stool to the guaiac paper.
c. Report a positive finding to the provider.
d. Don sterile disposable gloves.

c. Report a positive finding to the provider.

Rationale:

Abnormal findings such as a positive test (turns blue) 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.

20

A nurse is preparing a patient for a magnetic resonance imaging (MRI) scan. Which nursing action is most important?
a. Ensuring that the patient does not eat or drink 2 hours before the examination.
b. Administering a colon cleansing product 6 hours before the examination.
c. Obtaining an order for a pain medication before the test is performed.
d. Removing all of the patient’s metallic jewelry.

d. Removing all of the patient’s metallic jewelry.

Rationale:

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.

21

A patient with a fecal impaction has an order to remove stool digitally. In which order will the nurse perform the steps, starting with the first one?
1. Obtain baseline vital signs.
2. Apply clean gloves and lubricate.
3. Insert index finger into the rectum.
4. Identify patient using two identifiers.
5. Place patient on left side in Sims’ position.
6. Massage around the feces and work down to remove.
a. 4, 1, 5, 2, 3, 6
b. 1, 4, 2, 5, 3, 6
c. 4, 1, 2, 5, 3, 6
d. 1, 4, 5, 2, 3, 6

a. 4, 1, 5, 2, 3, 6

Rationale:

The steps for removing a fecal impaction are as follows: identify patient using two identifiers; obtain baseline vital signs; place on left side in Sims’ position; apply clean gloves and lubricate; insert index finger into the rectum; and gently loosen the fecal mass by massaging around it and work the feces downward toward the end of the rectum.

22

Before administering a cleansing enema to an 80-year-old patient, the patient says “I don’t think I will be able to hold the enema.” Which is the next priority nursing action?
a. Rolling the patient into right-lying Sims’ position
b. Positioning the patient in the dorsal recumbent position on a bedpan
c. Inserting a rectal plug to contain the enema solution after administering
d. Assisting the patient to the bedside commode and administering the enema

b. Positioning the patient in the dorsal recumbent position on a bedpan

Rationale:

If you suspect the patient of having poor sphincter control, position on bedpan in a comfortable dorsal recumbent position. Patients with poor sphincter control are unable to retain all of the enema solution. Administering an enema with the patient sitting on the toilet is unsafe because it is impossible to safely guide the tubing into the rectum, and it will be difficult for the patient to retain the fluid as he or she is in the position used for emptying the bowel. Rolling the patient into right-lying Sims’ position will not help the patient retain the enema. Use of a rectal plug to contain the solution is inappropriate and unsafe.

23

A nurse is providing care to a group of patients. Which patient will the nurse see first?
a. A child about to receive a normal saline enema
b. A teenager about to receive loperamide for diarrhea
c. An older patient with glaucoma about to receive an enema
d. A middle-aged patient with myocardial infarction about to receive docusate sodium

c. An older patient with glaucoma about to receive an enema

Rationale:

An enema is contradicted in a patient with glaucoma; this patient should be seen first. All the rest are expected. A child can receive normal saline enemas since they are isotonic. Loperamide, an antidiarrheal, is given for diarrhea. Docusate sodium is given to soften stool for patients with myocardial infarction to prevent straining.

24

A patient is diagnosed with a bowel obstruction. Which type of tube is the best for the nurse to obtain for gastric decompression?
a. Salem sump
b. Small bore
c. Levin
d. 8 Fr

a. Salem sump

Rationale:

The Salem sump tube is preferable for stomach decompression. The Salem sump tube has two lumina: one for removal of gastric contents and one to provide an air vent. When the main lumen of the sump tube is connected to suction, the air vent permits free, continuous drainage of secretions. While the Levin tube can be used for decompression, it is only a single-lumen tube with holes near the tip. Large-bore tubes, 12 Fr and above, are usually used for gastric decompression or removal of gastric secretions. Fine- or small-bore tubes are frequently used for medication administration and enteral feedings.

25

A patient had an ileostomy surgically placed 2 days ago. Which diet will 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 fresh pineapple and iced tea
c. Turkey meatloaf with white rice and apple juice
d. Fish sticks with sweet corn and soda

c. Turkey meatloaf with white rice and apple juice

Rationale:

During the first few days after ostomy placement, the patient should consume easy-to-digest soft foods such as poultry, rice, and noodles. Fried foods can irritate digestion. Foods high in fiber will be useful later in the recovery process but can cause food blockage if the GI tract is not accustomed to digesting with an ileostomy. Foods with indigestible fiber such as sweet corn, popcorn, raw mushrooms, fresh pineapple, and Chinese cabbage could cause this problem.

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. Emptying the pouch if it is more than one-third to one-half full
c. Thoroughly cleansing the skin around the stoma with soap and water to remove excess stool and adhesive
d. Measuring the correct size for the barrier device while leaving a 1/2-inch space around the stoma

b. Emptying the pouch if it is more than one-third to one-half full

Rationale:

Pouches must be emptied when they are one-third to one-half full because the weight of the pouch may disrupt the seal of the adhesive on the skin. The barrier device should be changed every 3 to 7 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. Avoid soap. It leaves a residue on skin, which may irritate the skin. The pouch opening should fit around the stoma and cover the peristomal skin to prevent contact with the effluent. Excess space, like 1/2 inch, allows fecal matter to have prolonged exposure to skin, resulting in skin breakdown.

27

The nurse will irrigate a patient’s nasogastric (NG) tube. Which action should the nurse take?
a. Instill solution into pigtail slowly.
b. Check placement after instillation of solution.
c. Immediately aspirate after instilling fluid.
d. Prepare 60 mL of tap water into Asepto syringe.

c. Immediately aspirate after instilling fluid.

Rationale:

After instilling saline, immediately aspirate or pull back slowly on syringe to withdraw fluid. Do not introduce saline through blue “pigtail” air vent of Salem sump tube. Checking placement before instillation of normal saline prevents accidental entrance of irrigating solution into lungs. Draw up 30 mL of normal saline into Asepto syringe to minimize loss of electrolytes from stomach fluids.

28

The nurse administers a cathartic to a patient. Which finding helps the nurse determine that the cathartic has a therapeutic effect?
a. Reports decreased diarrhea.
b. Experiences pain relief.
c. Has a bowel movement.
d. Passes flatulence.

c. Has a bowel movement.

Rationale:

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. An antidiarrheal will provide relief from diarrhea. Pain medications will provide pain relief. Carminative enemas provide relief from gaseous distention (flatulence).

29

An older adult’s perineal skin is dry and thin with mild excoriation. When providing hygiene care after episodes of diarrhea, what should the nurse do?
a. Thoroughly scrub the skin with a washcloth and hypoallergenic soap.
b. Tape an occlusive moisture barrier pad to the patient’s skin.
c. Apply a skin protective ointment after perineal care.
d. Massage the skin with light kneading pressure.

c. Apply a skin protective ointment after perineal care.

Rationale:

Cleansing with a no-rinse cleanser and application of a barrier ointment should be done after each episode of diarrhea. Tape and occlusive dressings can damage skin. Excessive pressure and massage are inappropriate and may cause skin breakdown.

30

Which action will the nurse take to reduce the risk of excoriation to the mucosal lining of the patient’s nose from a nasogastric tube?
a. Instill Xylocaine into the nares once a shift.
b. Tape tube securely with light pressure on nare.
c. Lubricate the nares with water-soluble lubricant.
d. Apply a small ice bag to the nose for 5 minutes every 4 hours.

c. Lubricate the nares with water-soluble lubricant.

Rationale:

The tube constantly irritates the nasal mucosa, increasing the risk of excoriation. Frequent lubrication with a water-soluble lubricant decreases the likelihood of excoriation and is less toxic than oil-based if aspirated. Xylocaine is used to treat sore throat, not nasal mucosal excoriation. While the tape should be secure, pressure will increase excoriation. Ice is not applied to the nose.