Bowel Elimination

Descripción

College-Level Nursing Block 3 Test sobre Bowel Elimination, creado por cpeters el 26/02/2015.
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Test por cpeters, actualizado hace más de 1 año
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Resumen del Recurso

Pregunta 1

Pregunta
During the nursing assessment a patient reveals that he has diarrhea and cramping every time he has ice cream. He attributes this to the cold nature of the food. However, the nurse begins to suspect that these symptoms are associated with:
Respuesta
  • Food allergy.
  • Irritable bowel.
  • Lactose intolerance.
  • Increased peristalsis.

Pregunta 2

Pregunta
When assessing a 55-year-old patient who is in the clinic for a routine physical, the nurse instructs the patient about the need to obtain a stool specimen for guaiac fecal occult blood testing (gFOBT):
Respuesta
  • If patient reports rectal bleeding.
  • When there is a family history of polyps.
  • As part of a routine examination for colon cancer.
  • If a palpable mass is detected on digital examination.

Pregunta 3

Pregunta
Which of the following medications listed in a patient's medication history possibly causes gastrointestinal bleeding? (Select all that apply.)
Respuesta
  • Aspirin
  • Cathartics
  • Antidiarrheal opiate agents
  • Nonsteroidal intiinflammatory drugs (NSDAIDS)

Pregunta 4

Pregunta
Nurses discourage patients from straining on defecation primarily because it causes: (Select all that apply.)
Respuesta
  • Pain
  • Impaction
  • Hemorrhoids
  • Dysrhythmias

Pregunta 5

Pregunta
A cleansing enema is ordered for a 55-year-old patient before intestinal surgery. The nurse understands that the maximum amount of fluid given is:
Respuesta
  • 150 to 200 mL
  • 200 to 400 mL
  • 400 to 750 mL
  • 750 to 1000 mL

Pregunta 6

Pregunta
A patient starts to experience pain while receiving an enema. The nurse notes blood in the return fluid and rectal bleeding. What action does the nurse take first?
Respuesta
  • Administers pain medication.
  • Slows down the rate of instillation.
  • Tells the patient to breathe slowly and relax.
  • Stops the instillation and obtains vital signs.

Pregunta 7

Pregunta
Number the steps to irrigating a nasogastric tube (NG) in correct order: 1) Slowly aspirate the syringe. 2) Reconnect the NG tube to suction. 3) Clamp and disconnect the NG tube. 4) Perform hand hygiene and apply clean gloves. 5) Insert tip of syringe into NG tube and slowly inject 30 mL saline.
Respuesta
  • 1, 2, 3, 4, 5
  • 4, 1, 3, 2, 5,
  • 4, 1, 2, 3, 5
  • 4, 3, 5, 1, 2

Pregunta 8

Pregunta
List the correct order in which to apply on ostomy pouch: 1) Remove the used pouch and skin barrier. 2) Perform hand hygiene and apply clean gloves. 3) Assess the stoma for color, swelling, and healing. 4) Gently cleanse the peristomal skin with warm tap water. 5) Apply nonallergenic tape around the pectin skin barrier. 6) Cut an opening on the pouch 0.15-0.3 cm larger than the stoma. 7) Press the adhesive backing of the pouch smoothly against the skin.
Respuesta
  • 2, 3, 5, 1, 7, 6, 4
  • 2, 1, 4, 3, 6, 7, 5
  • 2, 3, 1, 4, 6, 7, 5
  • 2, 1, 3, 4, 6, 7, 5

Pregunta 9

Pregunta
A patient is admitted for lower gastrointestinal (GI) bleeding. What color of stool does the nurse anticipate the patient to have?
Respuesta
  • Red
  • Black
  • Green
  • Orange

Pregunta 10

Pregunta
The nurse is caring for a patient with a colostomy. Which intervention is most important?
Respuesta
  • Cleansing the stoma with hot water
  • Inserting a deodorant tablet in the stoma bag.
  • Selecting a bag with an appropriate-size stoma opening.
  • Wearing sterile gloves while caring for the stoma.

Pregunta 11

Pregunta
The nurse understands that, when comparing nasogastric tubes used for gastric decompression, a Salem sump is specifically designed to:
Respuesta
  • Minimize the risk of bowel obstruction.
  • Ensure drainage of the intestines.
  • Prevent gastric mucosal damage.
  • Promote resting the gut.

Pregunta 12

Pregunta
Before collecting a stool sample for occult blood, the nurse instructs the nursing assistive personnel to:
Respuesta
  • Ask the patient to void.
  • Wash the patient's perineum.
  • Secure a sterile, specimen container.
  • Plan to collect the first specimen of the day.

Pregunta 13

Pregunta
The nurse is taking a helath history of a newly admitted patient with a diagnosis Rule/out bowel obstruction. Which of the following is the priority question to ask the patient?
Respuesta
  • Describe your bowel movements.
  • How often do you have a bowel movement?
  • When was the last time you moved your bowels?
  • Do you routinely use stool softeners, laxatives, or enemas?

Pregunta 14

Pregunta
The nurse is caring for a 78-year-old man with diarrhea. Of the following problems, which is the most important to consider?
Respuesta
  • Malnutrition
  • Dehydration
  • Skin breakdown
  • Incontinence

Pregunta 15

Pregunta
The nurse recognizes which patient needs to use a fracture pan for a bowel movement?
Respuesta
  • The patient who is obese.
  • The patient experiencing confusion.
  • The patient on bed rest.
  • A patient recovering from hip surgery.

Pregunta 16

Pregunta
Most nutrients and electrolytes are absorbed in the:
Respuesta
  • Colon
  • Stomach
  • Esophagus
  • Small intestine

Pregunta 17

Pregunta
Which of the following should be included in the teaching plan for the patient who is scheduled for an upper GI series?
Respuesta
  • The patient will be allowed nothing by mouth after midnight.
  • General anesthetic is usually used for the procedure.
  • Moderate abdominal pain is common after the procedure.
  • A cleansing enema will be given the evening before the procedure.

Pregunta 18

Pregunta
Mrs. Anthony is concerned about her breastfed infant's stool, stating that is is yellow instead of brown. The nurse explains to Mrs. Anthony that:
Respuesta
  • The stool is normal for an infant.
  • A change to formula may be necessary.
  • It will be necessary to send a stool specimen to the laboratory.
  • Her infant is dehydrated, and she should increase his fluid intake.

Pregunta 19

Pregunta
After positioning a patient on the bedpan, the nurse should:
Respuesta
  • Leave the head of the bed flat.
  • Raise the head of the bed 30 degrees.
  • Raise the bed to the highest working level.
  • Raise the head of the bed to a 90-degree angle.

Pregunta 20

Pregunta
The physician has ordered a cleansing enema for 7-year-old Michael. The nurse realizes the maximum volume to be given would be:
Respuesta
  • 100- 150 mL
  • 150- 200 mL
  • 300- 500 mL
  • 600- 700 mL

Pregunta 21

Pregunta
A nurse is caring for a client who will perform fecal occult blood testing at home. Which of the following information should the nurse include when explaining the procedure to the client?
Respuesta
  • Eating more protein is optimal prior to testing.
  • One stool specimen is sufficient for testing.
  • A red color change indicates a positive test.
  • The specimen cannot be contaminated with urine.

Pregunta 22

Pregunta
A nurse is talking with a client who reports constipation. When the nurse discusses dietary changes that can help prevent constipation, which of the following foods should the nurse recommend?
Respuesta
  • Macaroni and cheese
  • Fresh fruit and whole wheat toast
  • Rice pudding and ripe bananas
  • Roast chicken and white rice

Pregunta 23

Pregunta
A nurse is caring for a client who has had diarrhea for the past 4 days. When assessing the client, the nurse should expect which of the following findings? (Select all that apply.)
Respuesta
  • Bradycardia
  • Hypotension
  • Fever
  • Poor skin turgor
  • Peripheral edema

Pregunta 24

Pregunta
A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following are appropriate steps for the nurse to take? (Select all that apply.)
Respuesta
  • Warm the enema solution prior to instillation.
  • Position the client on the left side with the right leg flexed forward.
  • Lubricate the rectal tube or nozzle.
  • Slowly insert the rectal tube about 2 inches.
  • Hang the enema container 24 inches above the client’s anus.

Pregunta 25

Pregunta
While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following is the appropriate intervention?
Respuesta
  • Have the client hold his breath briefly.
  • Discontinue the fluid instillation.
  • Remind the client that cramping is common at this time.
  • Lower the enema fluid container.
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