Exam 2

Question 1

steps of ostomy care for a patient

Answer 1

Remove and dispose of the used ostomy pouch. Assess the integrity of the stoma and peristomal skin. Cleanse the area surrounding the stoma. Measure the stoma. Prepare the new pouch to fit stoma. Apply the new pouch.

Question 2

Which assessment cues would alert the nurse that the patient with diarrhea is declining?

Answer 2

Has two more episodes of liquid stools
Having two more episodes of liquid stools indicates the patient is declining.

Exhibits dry mucous membranes
Developing signs of dehydration (exhibiting dry mucous membranes) indicates the patient is declining.

Exhibits poor skin turgor

Question 3

Which stoma assessment cue would alert the nurse that the patient with a bowel diversion is deteriorating?

Answer 3

Moist, blue
A moist, blue stoma indicates the patient is declining/deteriorating, and the health care provider needs to be notified.

Question 4

Which action would the nurse take for a patient with a newly formed bowel diversion?

Answer 4

Perform stoma care him- or herself.
The nurse would not delegate this skill if the stoma is new or complications are present; thus, the nurse would perform stoma care because the patient has a new bowel diversion.

Question 5

Which task would the nurse delegate to the unlicensed assistance personnel (UAP) for a patient’s bowel elimination needs?

Answer 5

Record intake and output for a frail older adult.
The nurse can delegate recording intake and output to the UAP.

Question 6

Which action would the nurse take for a patient whose ostomy stoma is speckled white?

Answer 6

Notify the health care provider.
The health care provider is notified because the findings indicate the patient has probably developed a fungal infection.

Question 7

Which action would the nurse take if there are concerns during administration of the enema?

Answer 7

If the patient cannot hold the enema solution, place the patient on a bedpan.
If the patient cannot retain the enema, place the patient on a bedpan.

Question 8

Which patient statement would indicate to the nurse that the patient understands the teaching for an opiate-based antidiarrheal agent?

Answer 8

“I should take the medicine for no more than 72 hours.”
This statement indicates patient understanding. It is recommended that a patient limit use of opioid antidiarrheal drugs to 48 to 72 hours.

Question 9

For which constipated patient would the nurse administer a laxative?

Answer 9

One who is allergic to opiates
Laxatives are not opiate-based drugs; therefore the nurse would administer the laxative to this patient.

Question 10

Which laxative would the nurse observe written on the medication administration record (MAR) for a patient with a prescription for a stimulant?

Answer 10

Senna
The nurse would observe senna on the MAR. Senna is a type of stimulant cathartic laxative.

Question 11

For which primary purpose would the nurse insert a large-bore nasogastric tube in a patient who ate a poisonous substance?

Answer 11

Gastric lavage
A large-bore nasogastric tube allows the stomach to be irrigated with fluids to flush out poisons and blood.

Question 12

Which action would the nurse take first when there is no movement of fluid in the patient’s nasogastric tube and the patient’s abdomen is becoming distended?

Answer 12

Irrigate the tube with normal saline.
The nurse would irrigate the tube with normal saline first when there is no movement of fluid in the nasogastric tube and the patient’s abdomen is becoming distended.

Question 13

Which statements by a group of healthy adults indicate successful teaching by the nurse about colorectal health?

Answer 13

“Because I am 50, I need to have a fecal occult blood test every year.”
This statement reflects the recommended screening guidelines for fecal occult blood testing and indicates successful teaching.

“Because I have no personal or family history of colorectal cancer and am 50 years old, sigmoidoscopy or colonoscopy screening should begin now.”
Sigmoidoscopy and colonoscopy screening for colorectal polyps and early signs of cancer begins at age 45 to 50 for most people. This statement indicates successful teaching.

Question 14

Which information would the nurse share with a patient who wants to eat healthy and have an active lifestyle to improve digestive health?

Answer 14

Walking stimulates intestinal muscle contraction.
The nurse would include this information because aerobic exercise, like walking, stimulates contraction of intestinal muscles.

Usually 6 to 8 glasses of fluid should be consumed per day.
The nurse would include this information because the patient needs 6 to 8 glasses of fluid to keep feces soft.

Question 15

Which actions would the nurse take for a patient who has diarrhea and is becoming dehydrated?

Answer 15

Monitor intake and output.
The nurse would monitor intake and output for a patient with diarrhea and dehydration.

Weigh daily.
The nurse would weigh the patient daily, especially because dehydration is developing.

Assess skin turgor.
The nurse would assess skin turgor, especially because dehydration is developing.

Question 16

Which assessment cues alert the nurse that the patient with a fecal impaction is deteriorating?

Answer 16

Heart rate drops to 56 beats/min
A heart rate below 60 beats/min indicates the patient is declining/deteriorating.

Blood pressure elevates from 120/60 to 142/66 mm Hg
Blood pressure elevation by 20 to 40 mm Hg (120 to 142 mm Hg) indicates the patient is declining/deteriorating.

Question 17

Which actions would the nurse take when performing routine ostomy care on a patient with an ileostomy?

Answer 17

Measure the stoma.
Careful measurement of the stoma is necessary to prevent injury to the stoma or surrounding skin.

Assess the pouch seal.
The pouch is assessed to make sure the seal is secure to prevent leakage and potential skin breakdown.

Gently wash the stoma and peristomal area with water.
It is important to wash the stoma and surrounding area to prevent skin irritation and to enhance adherence of the pouch.

Question 18

Which nursing actions would the nurse perform directly after completion of a cleansing enema to an ambulatory patient?

Answer 18

Assisting the patient to the bathroom
Because the patient can walk to the bathroom, the nurse would assist the patient to the bathroom.

Ensuring that nonskid shoes/socks are in place
For safety, the patient would wear nonskid footwear to prevent falls.

Question 19

Which cues would alert the nurse that a patient with a nasogastric tube is experiencing aspiration?

Answer 19

Fever
Temperature (fever) occurs with aspiration.

Congested lung sounds
Lung congestion or congested lung sounds occur with aspiration.

Shortness of breath
Dyspnea, or shortness of breath, occurs with aspiration.

Question 20

After how many enemas would the nurse notify the health care provider when the patient’s bowel return for cleansing enemas is still brown? Record your answer as a whole number. __ enemas

Answer 20

3

Question 21

Which processes are functions of the large intestine?

Answer 21

Secretion
Secretion is a function of the large intestine. The large intestine secretes bicarbonate in exchange for chloride.

Elimination
Elimination is a function of the large intestine. The large intestine eliminates potassium, feces, and flatus.

Absorption
Absorption is a function of the large intestine. The large intestine absorbs water continually from chyme, converting it to solid feces/stool.

Question 22

The gastrointestinal tract has which function?

Answer 22

Absorption of nutrients and fluids
The gastrointestinal tract absorbs nutrients and fluids.

Question 23

Which structure is the primary organ that aids in defecation?

Answer 23

Large intestine
The large intestine is the principal organ of bowel elimination and aids in defecation.

Question 24

Which function does defecation serve?

Answer 24

Expels feces
Defecation expels feces/stool from the body. The ultimate function of the large intestine and the final act of digestion to produce feces and expel it from the body. In nursing this is called a bowel movement or stool.

Question 25

Which information is accurate regarding the structure and function of the esophagus?

Answer 25

Connects the pharynx to the stomach The esophagus connects the pharynx to the stomach. Is a collapsible tube that transports a food bolus The esophagus is a collapsible tube that transports a food bolus.

Question 26

Which factors can affect a patient’s bowel movements?

Answer 26

Dietary intake Dietary intake can affect a person’s bowel movements by affecting the consistency (hard, soft) of stools. Medication use Medication use can affect a person’s bowel movements by either causing diarrhea or constipation. Pain Pain can affect a person’s bowel movements by suppressing the urge to defecate. Recent surgery Recent surgery can affect a person’s bowel movements by slowing peristalsis.

Question 27

Which information regarding the frequency of bowel movements is accurate?

Answer 27

Varies from person to person The frequency of defecation, along with the characteristics of feces, will vary and differs from person to person.

Question 28

Which amount of fluid (in ounces) is recommended for an adult to maintain healthy bowel elimination?

Answer 28

64

Question 29

Which question addresses psychological factors that can affect a patient’s bowel elimination?

Answer 29

Is the patient experiencing stress? Stress is a psychological condition that can affect elimination. Stress can lead to diarrhea.

Question 30

Which medications would increase the patient’s risk for constipation?

Answer 30

Opioids Opioids increase the likelihood of constipation. Correct Antacids Antacids increase the likelihood of constipation. Iron supplements Iron supplements increase the likelihood of constipation.

Question 31

Which type of intestinal movement would a patient with a paralytic ileus have?

Answer 31

None If the intestines are manipulated during surgery, intestinal movement stops (none), causing a paralytic ileus.

Question 32

Which information would the nurse share with a patient who has a loop colostomy?

Answer 32

“After your bowels heal, they will be reattached.” With a temporary colostomy, the bowels will be reattached after healing occurs.

Question 33

Which type of procedure creates no stoma on the patient‘s abdomen?

Answer 33

Ileoanal pouch An ileoanal pouch is a reservoir in the abdomen that collects stool. It does not have a stoma because it is connected to the anus.

Question 34

Which characteristics are typical of a loop colostomy?

Answer 34

Has one stoma with two openings This is a characteristic of a loop colostomy. A loop colostomy has one stoma with two openings. Correct Has mucus drain from the distal end of the stoma This is a characteristic of a loop colostomy. The distal end discharges mucus in a loop colostomy. Correct Has stool drain from the proximal end of the stoma This is a characteristic of a loop colostomy. Stool drains from the proximal end in a loop colostomy. Is usually created in an emergency This is a characteristic of a loop colostomy. A loop colostomy is usually created in an emergency.

Question 35

Stool drainage from a sigmoid colostomy has which characteristics?

Answer 35

Well-formed Well-formed stools are indicative of a sigmoid colostomy. The location of the sigmoid colon allows the stool to stay in the intestine longer and has a more normal consistency. Well-regulated The stools can be well regulated in a sigmoid colostomy.

Question 36

Which type of ostomy causes the patient to lose a large amount of water, electrolytes, and digestive enzymes through a stoma?

Answer 36

Ileostomy The patient with an ileostomy loses a high volume of water, electrolytes, and digestive enzymes through a stoma.

Question 37

From which area would the nurse observe stool draining in a double-barrel colostomy?

Answer 37

Proximal end The functional proximal end, closest to the small intestine, drains feces/stool.

Question 38

Which question would the nurse ask first to obtain information about the patient’s bowel habits? “Where is your abdominal pain?” “Do you have any bloating or gas?” “How many bowel movements do you have a day?” “What medications do you take on a regular basis?”

Answer 38

“How many bowel movements do you have a day?”

Question 39

Which assessment technique for the abdomen is performed last to avoid a false finding? Palpation Inspection Auscultation Patient interview

Answer 39

Palpation

Question 40

Which assessment findings indicate the patient has hyperactive bowel sounds? Select all that apply. Tinkling sound Rushing sound Fewer than five sounds per minute Sounds occur every 5 to 15 seconds High-pitched sound Soft gurgling sound

Answer 40

Tinkling sound Rushing sound High-pitched sound

Question 41

The patient’s stool culture will help detect which finding? Cancer Intestinal polyps Abnormal bacteria Small amounts of blood

Answer 41

Abnormal Bacteria

Question 42

Which cue is irrelevant for a patient with constipation? Expels hard, pebble-like stools Does not like to exercise Has an abnormal serum creatinine level Eats low-fiber foods

Answer 42

Has abnormal serum creatinine level

Question 43

Which cues would the nurse expect to observe in a patient suffering from diarrhea? Select all that apply. Hyperactive bowel sounds Excessive straining to pass stool Abdominal pain Continuous leaking of liquid stool Urgency Hemorrhoids noted in medical history

Answer 43

Hyperactive bowel sounds Abdominal Pain Urgency

Question 44

Which relevant cues would the nurse share with the health care provider when consulting about a patient who has developed constipation? Select all that apply. Bed linens are soiled with stool. Graphic record shows no stool in 2 days. Patient strains while trying to have a bowel movement. Patient reports urgency and abdominal cramping. Decreased bowel sounds auscultated.

Answer 44

Graphic record shows no stool in 2 days PT strains while trying to have a bowel movement Decreased bowel sounds auscultated

Question 45

Which patient is at risk for developing an impaction? One who is immobile One who is lactose intolerant One who is infected with Clostridium difficile One who is receiving enteral feedings

Answer 45

One who is immobile

Question 46

Which cause would the nurse consider if the patient is experiencing flatulence? Unconsciousness Loss of nerve sensation Inability of anal sphincters to work properly Action of bacteria on chyme

Answer 46

Action of bacteria on chyme

Question 47

Which question would the nurse ask to gather cues about drug-related issues for bowel elimination? “Are you using any herbal supplements?” “Do you have any bloating or gas?” “When did this start?” “Where is the pain?”

Answer 47

A

Question 48

Which finding would the nurse categorize as an expected finding for an abdominal assessment? Presence of visible peristaltic waves Nonprotruding midline umbilicus Asymmetrical abdomen Ascites

Answer 48

B

Question 49

Which information would the nurse share with the patient about how blood can be detected in a guaiac test? A small amount of feces is applied to a special medium for growing microorganisms. The stool sample is exposed to a special chemical that changes color when blood is present. Feces is placed on a slide and visualized under a microscope, noting any blood. Stool is viewed under special lighting, showing reddish streaks if blood is present.

Answer 49

B

Question 50

Which action by the new nurse while performing an abdominal assessment would cause the charge nurse to intervene? Auscultates before palpates Turns off the nasogastric suction while auscultating Palpates a pulsating midline mass Communicates with the patient in a matter-of-fact manner

Answer 50

C

Question 51

Which action would the nurse take when performing an abdominal assessment? Interviews the patient after the physical assessment Palpates the area of pain last Percusses the abdomen routinely Auscultates with cooled stethoscope

Answer 51

B

Question 52

Which expected assessment cue would the nurse find upon palpation of the abdomen? Hard Rough Painless Mass-filled

Answer 52

C

Question 53

Which diagnostic study would help determine whether there is bleeding in the patient’s stomach? Barium enema Lower gastrointestinal (GI) series Esophagogastroduodenoscopy Colonoscopy

Answer 53

C

Question 54

Which cues would be anticipated in a patient with flatulence and bloating? Select all that apply. Abdominal tenseness on palpation Visible peristaltic waves Feelings of nausea Reports passing excessive gas through the rectum Reports of abdominal pressure

Answer 54

A, D, E

Question 55

Which bowel assessment findings would the nurse report as unexpected? Select all that apply. Rebound tenderness present Active bowel sounds Steatorrhea Clay-colored, round stool Symmetrical abdomen

Answer 55

A,C,D

Question 56

Which findings would cause the nurse to document “active” bowel sounds? Select all that apply. Gurgling Soft High-pitched Sounds every 5 to 15 seconds Irregular pattern

Answer 56

A, B, D, E

Question 57

How long would the nurse auscultate the abdomen before documenting no or absent bowel sounds? Record answer as a whole number. minutes Use numbers only.

Answer 57

5

Question 58

Place in the correct order the steps to perform a complete assessment of bowel function. Auscultation Inspection Interview Palpation

Answer 58

iNTERVIEW iNSPECTION AUSCULTATION PALPATION

Question 59

Which patient requires immediate medical attention? A patient with a distended abdomen A patient with a mass in the abdomen A patient with hypoactive bowel sounds A patient with a hard, boardlike abdomen

Answer 59

D

Question 60

Which cue is irrelevant for a patient with a bowel alteration? Type of hypertension Type of bowel sounds Type of lifestyle Type of diet

Answer 60

A

Question 61

The nurse caring for a patient suffering from chronic constipation must be aware of which potential complication? Incontinence Dehydration Clostridium difficile (C. diff) infection Fecal impaction

Answer 61

D

Question 62

Which cause is the likely reason a patient on long-term antibiotic therapy is experiencing frequent, foul-smelling diarrhea? Foodborne pathogens Excessive laxative use Clostridium difficile Food intolerances

Answer 62

C

Question 63

Which location in the medical record would the nurse check to determine the date of the patient’s last bowel movement? Vital signs graph Graphic chart Laboratory results Medical history

Answer 63

B

Question 64

Which characteristic describes bowel sounds auscultated in a patient with constipation? Fewer than five per minute Tinkling Soft, gurgling Rushing

Answer 64

A

Question 65

Which factors could be potential sources of a patient’s flatus? Select all that apply. History of recent abdominal surgery Use of bran for fiber Increased activity level Presence of milk intolerance Current diet

Answer 65

A,B,D,E

Question 66

The nurse understands that patients may experience diarrhea due to which causes? Select all that apply. Psychological stress Inadequate liquid intake Antibiotic use Enteral nutrition Barium enema

Answer 66

A, C, D

Question 67

Which cues suggest bowel alteration due to impaction? Select all that apply. Has not had a bowel movement in 4 days Has bacteria in stool specimen Has hyperactive bowel sounds Has palpable hard fecal mass Has continuous leakage of liquid stool

Answer 67

A, D, E

Question 68

Which patients are immediate concerns? Select all that apply. A teenager with absent bowel sounds A young adult who ate onions and beans A middle-aged adult with bowel incontinence A young child with diarrhea who develops dehydration An older adult who is positive for Clostridium difficile (C. diff) stool culture

Answer 68

A,D,E

Question 69

Match each bowel alteration to its cause. Prolonged constipation Select an answer Paralyzed rectum muscles Select an answer Slowed peristalsis Select an answer Increased peristalsis Select an answer Options are: Impaction Incontinence Diarrhea Constipation

Answer 69

Prolonged Constiption: Impaction Paralyzed Rectum Muscles: Incontnence Slowed Peristalsis: Constipation Increased Peristalsis: Diarrhea

Question 70

Which cues support the hypothesis of Constipation for a patient? Select all that apply. Limited mobility Receives narcotic pain medication Decreased fluid intake Female sex Hyperactive bowel sounds

Answer 70

Limited mobility Limited mobility is a cue for Constipation. Receives narcotic pain medication Receiving narcotic pain medication is a cue for Constipation. Decreased fluid intake A decreased fluid intake is a cue for Constipation.

Question 71

Which interpretation would the nurse make about a patient who says, “I only had one bowel movement this week”? This is abnormal. The patient is constipated. This may be an expected or unexpected finding. The patient has a fecal impaction.

Answer 71

This may be an expected or unexpected finding. This is the only interpretation the nurse can make about this patient at this time. Individual “normals” must be determined before making a judgment on whether it is an expected or unexpected finding.

Question 72

Which cues would prompt the nurse to develop a hypothesis of Dehydration for a patient? Select all that apply. Numerous semiliquid stools Output more than intake Dry mouth Abdominal stoma No bowel movement in several days

Answer 72

Numerous semiliquid stools Numerous semiliquid stools is a cue for Dehydration from a loss of fluids. Output more than intake Output more than intake is a cue for loss of fluid leading to Dehydration. Dry mouth Dry mucous membranes (mouth) is a cue for Dehydration.

Question 73

Which overall elimination goal is appropriate for a patient with a decrease in the frequency of bowel movements? Prevent diarrhea. Maintain normal defecation. Enhance body image. Relieve constipation.

Answer 73

Relieve constipation. The overall goal is to relieve constipation because the patient is experiencing a decrease in the frequency of bowel movements.

Question 74

Which hypothesis would the nurse address first for a patient having continuous seepage of liquid stool? Impaired Ability to Manage Stoma Care Constipation Fecal Impaction Impaired Self-Toileting

Answer 74

Fecal Impaction Fecal Impaction is the hypothesis to address first. Seeping liquid stool is a cue for Fecal Impaction.

Question 75

Which solution would the nurse consider for a patient with constipation who is on bed rest? Ambulation Consultation with a wound, ostomy, and continence nurse (WOCN) Consumption of foods that produce gas Patient education about fluid needs

Answer 75

Patient education about fluid needs The nurse would consider patient education about fluid needs for constipation.

Question 76

Which outcome would the nurse include for a patient with a hypothesis of reluctant to care for stoma? Patient will be able to wear a pouch only when in public. Patient will state one good aspect about body. Patient will contribute to self-care after toileting. Patient will assist with ileostomy care daily.

Answer 76

Patient will assist with ileostomy care daily. Patient will assist with ileostomy care daily is related to the hypotheses of reluctant to care for stoma and indicates the hypothesis has been resolved in measurable terms.

Question 77

Which SMART outcomes would the nurse add to a plan of care for a patient with dehydration? Select all that apply. Patient will have moist mucous membranes. Patient will have supple skin turgor within 48 hours. Patient will have good urine output. Patient will have a moist mouth throughout hospital stay. Patient will have adequate fluid intake at breakfast.

Answer 77

Patient will have supple skin turgor within 48 hours. Having supple skin turgor within 48 hours is a SMART outcome because it is specific, realistic, measurable, patient-centered, attainable, and has a time frame. Patient will have a moist mouth throughout hospital stay. Having a moist mouth throughout hospital stay meets all the requirements for a SMART outcome because it is specific, realistic, measurable, patient-centered, attainable, and has a time frame.

Question 78

Which cue would prompt the nurse to select a hypothesis of Bowel Incontinence for a patient? Abdominal distention noted on inspection No stool in 3 days per patient report Intermittent soiling from soft feces Hypoactive bowel sounds

Answer 78

C

Question 79

Which hypothesis would the nurse develop for a patient who states, “I can’t stand to look at the stoma or this colostomy bag”? Disturbed Body Image Impaired Self-Toileting Risk for Impaired Skin Integrity Diarrhea

Answer 79

A

Question 80

Which primary pathophysiologic process would the nurse conclude is occurring in a patient who has a hypothesis of Diarrhea? Quick transit time reducing water absorption Engorged rectal veins Neurologic impairment to control bowels Exposed skin to stool enzymes

Answer 80

A

Question 81

The nurse would consider which pathophysiologic factor when caring for a patient with dementia whose bed linens are soiled several times a day? Altered mobility issues Impaired neurologic status Impaired muscular functioning Altered gastrointestinal transit time

Answer 81

B

Question 82

Which hypothesis would the nurse select for a patient who has hyperactive bowel sounds, abdominal cramping, and liquid stools? Fecal Impaction Bowel Incontinence Diarrhea Constipation

Answer 82

C

Question 83

The nurse would develop a hypothesis of Risk for Impaired Skin Integrity for which patient? A patient with an ostomy created from the ileum A patient whose intake is less than output A patient whose abdomen is distended A patient with active bowel sounds

Answer 83

A

Question 84

Which patient situation would the nurse prioritize as the most critical? Choking on food, closing airway Having hypoactive bowel sounds Experiencing severe flatulence Passing excessive watery stools

Answer 84

A

Question 85

The nurse recognizes that the outcome of “Patient will pass soft stools daily during rehabilitation” directly applies to which hypothesis? Constipation Dehydration Impaired Self-Toileting Risk for Impaired Skin Integrity

Answer 85

A

Question 86

Which member of the multidisciplinary team would the nurse include in caring for a patient who has impaired manual dexterity for toileting? Nutritionist/dietitian Physical therapist Mental health professional Wound, ostomy, and continence nurse

Answer 86

B

Question 87

Which solution would the nurse consider for a patient with flatulence who is in traction? Consultation with a mental health professional Institution of isolation precautions Ambulation of patient Avoidance of foods that produce gas

Answer 87

D

Question 88

Which overall goal would the nurse focus on while caring for a patient with severe diarrhea? Maintain normal elimination patterns. Prevent dehydration. Relieve hard stools. Avert fecal impaction.

Answer 88

B

Question 89

Which overall goal would the nurse select for a patient who has occasional fecal incontinence? Maintain intact skin. Promote hydration. Prevent constipation. Relieve flatus.

Answer 89

A

Question 90

Which elimination outcome indicates the nurse has considered the physical abilities of the patient in a coma? The patient will assist with self-toileting this afternoon. The patient will walk to the bathroom with assistance after breakfast. The patient will have intact skin after each bowel movement. The patient will report passage of a soft stool this morning.

Answer 90

C

Question 91

Which hypothesis is associated with the patient outcome “Patient will defecate without burning or pain while hospitalized”? Constipation Fecal Impaction Hemorrhoid Bowel Incontinence

Answer 91

C

Question 92

Which cues would prompt the nurse to select a hypothesis of Risk for Constipation for a patient? Select all that apply. Is on a high-fiber diet Has increased intestinal motility Has poor fluid intake Is on complete bed rest Has an ileostomy

Answer 92

C,D

Question 93

Which cues would prompt the nurse to develop the hypothesis of Impaired Self-Toileting for a patient? Select all that apply. Weakness in left leg Paralysis of the lower extremities Hemiparesis on the right side Cramping in the abdomen Bloated stomach

Answer 93

A,B,C

Question 94

Which cues support the nurse formulating a hypothesis of Constipation for a patient? Select all that apply. “My stools are like little hard stones.” “I sometimes lose control of my bowels.” “I watch a lot of movies for entertainment.” “My wife makes me eat a bran muffin every morning.” “I frequently take an opioid medication for my back pain.”

Answer 94

A,C,E

Question 95

Which multidisciplinary team members would the nurse likely collaborate with when caring for a patient who has constipation from a low-fiber diet and pain medications and needs assistance with self-toileting from hip surgery? Select all that apply. Health care provider Nutritionist/dietitian Physical therapist Mental health professional Wound, ostomy, and continence nurse

Answer 95

A,B,C

Question 96

Which goals would the nurse select for a patient with frequent watery stools? Select all that apply. Patient will pass soft stool within 48 hours. Patient will defecate formed stool within 24 hours of treatment. Patient will have two fewer episodes of diarrhea within 24 hours. Patient will assist with self-care after toileting within 2 days. Patient will consume less than 1000 mL of fluid daily.

Answer 96

A,B,C

Question 97

Which solutions would the nurse select for a patient with diarrhea caused by Clostridium difficile (C. diff)? Select all that apply. Laxative administration Fluid measures Fecal management system Isolation precautions Intake and output monitoring

Answer 97

B.D.E

Question 98

Which hypotheses relate to the outcome of patient will pass soft, formed stools? Select all that apply. Constipation Diarrhea Fecal Impaction Risk for Impaired Skin Integrity Impaired Ability to Manage Stoma Care

Answer 98

A,B,C

Question 99

The nurse is carring for a patient with malabsorption syndrome. Which change in bowel elimination is the patient likely to report?

Answer 99

Pale stools Oily stools

Question 100

The nurse provides education for a group of community members about colorectal cancer. Which warning sign of cancer would be included?

Answer 100

Rectal Bleeding Change in bowel habits

Question 101

What is the recommended daily fluid intake for men?

Answer 101

3.7

Question 102

Which type of laxative acts by causing the stool to absorb water and swell?

Answer 102

Bulk forming

Question 103

A parent tells the nurse, "My infant who is breastfed passes stools an average of 5 times per day." Which response would the nurse provide to the parent?

Answer 103

"This is a normal finding for an infant."

Question 104

The nurse assesses a 55 year old patient as part of a routine physical. Based on which criterion would the nurse instruct the patient to obtain a stool specimens for guaiac fecal occult blood testing (gFOBT)?

Answer 104

If the patient is experiencing no bowel elimination problems

Question 105

The nurse is caring for a patient who has a colostomy. When assessing the stoma, which color indicates that the stoma is healthy?

Answer 105

Pink Red

Question 106

Which cause would the nurse suspect when mucus is noted in a patient's feces?

Answer 106

Intestinal infection

Question 107

A pateint with renal dysfunction experiences constipation. Which medication would the nurse avoid in this patient when managing the constipation?

Answer 107

Magnesium hydroxide

Question 108

A patient experiences chronic constipation but has no other symptoms, which medication would the nurse anticipate the health care provider to prescribe to provide relief for the condition

Answer 108

Polycarbophil

Question 109

Which constituent of feces is normal?

Answer 109

Bile pigment Dead bacteria Cells lining the intestinal mucosa

Question 110

Which complication may result from a patient who regularly ingests castor oil to relieve constipation?

Answer 110

Abdominal cramping Fluid and electrolyte imbalance

Question 111

Which sign magnifest in infants and young children who are dehydrated?

Answer 111

High Fever Sunken eyes Dry eyes when crying Listlessness or irritability

Question 112

A patient presents with abdominal discomfort and the nurse auscultates 40 bowel sounds in 1 min. Which pattern of bowel sounds does the nurse document

Answer 112

Hyper active

Question 113

The nurse observes teh presence of tympanic note when percussing the abdomen of a PT. Which causes would the nurse suspect?

Answer 113

Gas

Question 114

When sybstance indicates an abnornality when the nurse analyzes the characteristics of a pt's feces?

Answer 114

Excess fat Blood Mucus

Question 115

A PT reports passing black and tarry stools. The nurse identifies that the patient should be evaluated for which condition

Answer 115

Iron Ingestion Gastrointestinal Bleeding

Question 116

An older adult african american PT reports a change in bowel bahits with rectal bleeding and a sense of incomplete bowel evacuation. Which disorder would the nurse suspect in this PT?

Answer 116

Colon Cancer

Question 117

Which substance may cause complications for a patient who has kidney dysfunction?

Answer 117

Magnesium Hydroxide

Question 118

A PT reports passing narrow pencil-shaped stools over the past few days. Which cause would the nurse suspect for the assessment finding?

Answer 118

Obstruction Increased peristalsis

Question 119

A PT needs a bowel preparation before a procedure. Which medication would the nurse anticipate will be prescribed?

Answer 119

Sodium Phosphate

Question 120

Which frequesncy of defecation is abnormal for an infant?

Answer 120

No more than 6 times per day

Question 121

The nurse cares for an infant in the neonatal unit who is being breastfed. How often should the infant pass stools?

Answer 121

6 times per day

Question 122

A PT has been diagnosed with malabsorption of fat from the intestine. Which appearance with the PTs stools have

Answer 122

Pale and oily

Question 123

Which findings in a PT's stool analysis indicates an abnormality?

Answer 123

pus mucus

Question 124

Whch number of seconds between consecutive bowel sounds is a normal finding?

Answer 124

Normal is between 5 and 15 seconds

Question 125

Which action would the nuse take when collecting a guaiac fecal occult blood test (gDOBT)?

Answer 125

Interpret the color of the guaiac paper after 30-60 seconds

Question 126

A PT is admitted to the emergency department after the ingestion of a poison. Which type of cathartic would the nurse anticipate being prescribed to the PT?

Answer 126

Magnesium citrate

Question 127

Which assessment finding would cause the nurse to suspect that a PT has a bowel obstruction

Answer 127

Cramping; absence of bowel movements

Question 128

Which information does the nurse consider when caring for PTs of varying ages with disorders of bowel elimination?

Answer 128

The ability to controle defecation is absent until 2-3 years of age.

Question 129

On auscultating the abdomen of a PT with a stethoscope, the nurse hears high-pitched and hyperactive bowel sounds. Which condition corresponds with the assessment findings?

Answer 129

Small intestine obstruction

Question 130

A PT is scheduled for a plain film x-ray of the kidney, ureter, and bladder. Which preparation will be included on the PT's treatment plan

Answer 130

No Preparation required

Question 131

Which tube is appropriated as an intervention for bleeding esophageal varices

Answer 131

Sengstaken-Blakemore

Question 132

When comparing the nasogastric tube used for gastric decompression, the nurse recognizes which specific purpose of the Salem Sump?

Answer 132

Allow for stomach decompression and provide an air vent.

Question 133

A PT tells the nurse "I have been using a laxative for so long that it is nearly impossible to defecate without it." Which lacative would cause this type of dependence?

Answer 133

Senna