Unit 6 Review

The nurse is participating in a health screening clinic and is preparing materials about colorectal cancer. The nurse would include which risk factor for colorectal cancer in the material?

Personal history of ulcerative colitis or gastrointestinal (GI) polyps Common risk factors for colorectal cancer include age over 40 years; first-degree relative with colorectal cancer; high-fat, low-fiber diet; and history of bowel problems such as ulcerative colitis or familial polyposis.

The nurse is collecting data about how well a client diagnosed with a gastrointestinal (GI) disorder is able to absorb food. While doing this, the nurse recalls that absorption is most concerned with which bodily function?

The transfer of digested food molecules from the GI tract into the bloodstream Absorption is the transfer of digested food elements into the bloodstream. The blood then carries nutrients to the cells. Active transport is the process used to transfer nutrients into the cells. Digestion involves the mechanical and chemical breakdown of foods. Option 1 is an incorrect statement.

An elderly male patient has a poor diet and chronic constipation. The best recommendation from the nurse would be

fiber supplement daily. The elderly man does not take in sufficient fiber because of his poor diet. Supplementing with fiber will help to prevent constipation. Mineral oil interferes with vitamin absorption. Better fluid intake will help to prevent constipation. A fiber supplement is a better choice than laxatives

The nurse has documented that a patient has had two episodes of steatorrhea, which means that the character of the stool is:

frothy and foul smelling.

A patient has been ordered to have a 24-hour urine collection as part of a diagnostic workup. The action taken to perform this procedure correctly is to:

have the patient void at the beginning of the collection and throw it away.

Which is an appropriate question to ask to determine the specific type of incontinence?

"Have you been experiencing any urgency accompanied by dribbling or leaking urine?" Stress incontinence is caused by coughing, laughing, and other activities that increase intra-abdominal pressure. Reflex incontinence, sometimes called "overflow incontinence," is a loss of urine that is uncontrollable and occurs at predictable intervals. Functional incontinence is also involuntary and occurs often in clients with cognitive deficits, although the urinary and nervous systems are intact. Urge incontinence occurs following the sensation of an urgent need to void.

The nurse evaluates that there is a need for further teaching on bowel elimination when the client makes which statement?

"I need to decrease fiber in my diet." Adequate dietary fiber is an important factor for improving bowel function. Dietary fiber increases fecal weight and water content and accelerates the transit of the fecal mass through the gastrointestinal (GI) tract. The retention of water by the fiber has the ability to soften stools and promote regularity. Fluid intake and exercise also facilitate bowel elimination.

The nurse is told by an older woman that she has begun to be incontinent of urine at night and now drinks no fluids after 6.00 pm. Which is the nurse's best response?

"Incontinence at any age should be evaluated by your primary health care provider." Urinary incontinence requires evaluation as to the cause so that appropriate treatment can begin. Incontinence is not expected in old age, and the statement about expecting incontinence represents stereotypical thinking. It is not correct to say that older adults do not need as much fluid intake as younger adults. This is also stereotypical thinking. The idea that most adults are able to judge fluid needs may be true generally but may not apply because of the development of this new problem.

To prevent changes in the chemical characteristics of urine, a nurse sends a sample of fresh urine to the laboratory for urinalysis within at least:

5 to 10 minutes

A nurse is documenting the removal of a urinary drainage catheter from an assigned patient. If the catheter is removed at 9:00 AM, the nurse recognizes that the patient is due to void by:

5:00 PM.

A client with a neurological impairment experiences urinary incontinence. Which nursing action would help the client adapt to this alteration?

Establishing a toileting schedule A bladder retraining program, such as use of a toileting schedule, may be helpful to clients experiencing urinary incontinence. An indwelling urinary catheter should be used only when necessary because of risk of infection. Use of diapers or pads is the least acceptable alternative because the risk of skin breakdown exists.

A clear liquid diet has been prescribed for a client with gastroenteritis. Which item is appropriate to offer to the client?

Fat-free beef broth A clear liquid diet consists of foods that are relatively transparent. Soft custard and orange juice would be included in a full liquid diet because they are opaque, not clear. Clam chowder is opaque and also includes pieces of clams, thus eliminating it from a full liquid diet.

The nurse is assisting with the insertion of a nasogastric tube into a client. The nurse would place the client in which position for insertion?

High-Fowler's position Before insertion of a nasogastric tube the nurse places the client in a sitting or high-Fowler's position to reduce the risk of pulmonary aspiration if the client should vomit. A pillow may be placed behind the head and shoulders to promote the client's ability to swallow during procedure. Options 1, 2, and 4 do not facilitate the insertion of the tube or prevent aspiration.

An older client complains of chronic constipation. Which instructions would the nurse reinforce with the client? Select all that apply.

Increase fluids to at least 8 glasses a day. Respond in a timely manner to the urge to defecate Increase of fluid intake and dietary fiber will help change the consistency of the stool and make it easier for the client to pass. Clients should respond to the feeling of peristalsis involved with the urge to defecate. Some older clients with mobility issues may not respond to the urge. Increasing the intake of rice and bananas will increase constipation. Increasing sugar-free products and potassium in the diet will not be beneficial to the client.

The nurse is assisting in planning stress management strategies for the client diagnosed with irritable bowel syndrome. Which suggestion is most appropriate for the nurse to give to the client?

Learn measures such as biofeedback or progressive relaxation Treatment for irritable bowel syndrome includes stress reduction measures such as biofeedback, progressive relaxation, and regular exercise. The client should also learn to limit responsibilities. Other measures include increased fluid and fiber in the diet as prescribed and antispasmodic or sedative medications as needed.

The nurse is admitting a client to the nursing unit who has returned from the postanesthesia care unit following prostatectomy. The client has a three-way Foley catheter with continuous bladder irrigation. The nurse would maintain the flow rate of the continuous bladder infusion to maintain which urine output characteristic?

Pale yellow or slightly pink Bladder irrigant is not infused at a preset rate, but rather it is increased or decreased to maintain urine that is clear or pale yellow or that has just a slight pink tinge. The infusion rate should be increased if the drainage is red or if clots are seen. Correspondingly, the rate can be slowed slightly if the returns are as clear as water.

The nurse has inserted a nasogastric (NG) tube in a client and is checking for the correct placement of an NG tube. Which is the most reliable data to ensure that the end of the tube is in the stomach?

Placement is verified on x-ray The end of the NG tube should be in the stomach. An x-ray is the most reliable method of determining correct placement. The radiologist may recommend moving the tube backward or forward for a preferable placement. A low pH such as 4.5 of the fluid aspirated is likely to be from the stomach, but pH is affected by tube feeding formulas and prescribed proton-pump inhibitors. The characteristic bile green is highly suggestive that the tube is in the stomach. Auscultation of the air injection is not recommended as a reliable method to establish correct placement.

A female patient has had a knee replacement and is experiencing difficulty voiding. What should the nurse recommend?

Pour warm water over the perineum while patient attempts to void. Warm water may help patients to initiate the voiding reflex. Catheterization is used after other techniques have been unsuccessful. A physician order is needed for use of Crede's maneuver and/or a sitz bath.

A nurse has performed abdominal assessments on four patients. After reviewing the findings, the nurse is least concerned about problems with bowel elimination for the patient with:

abdomen nondistended, soft, with active bowel sounds in all four quadrants

A nurse notes that a patient has not had a stool for 2 days. The initial action of the nurse should be tO

ask about the patient's normal bowel pattern. It is normal for many people to have a bowel movement only every 2 to 3 days. Asking about the patient's normal bowel pattern should be the nurse's initial action. Additional patient information should be obtained prior to offering an enema, giving a stool softener, or scheduling a GI consult.

Interventions for a patient with diarrhea include

clear liquid diet. A clear liquid diet will allow the bowel to rest. A soft diet is not an appropriate intervention for the patient with diarrhea. Replacing fluids is necessary in a patient with diarrhea. Monitoring of electrolytes is more frequent than every 10 days as a result of the need for electrolyte replacement.

The nurse reports that her patient's stools are black and tarry. The nurse should document the stool as

melena. Melena occurs as blood moves through the stomach or small intestine; it undergoes partial digestion, which changes it to a dark, tarry substance (melena). Blood-tinged is not a correct description. Streatorrhea is stools with an abnormally high fat content that float on water. Hemorrhagic is not a correct description

The nurse caring for a patient who had a colostomy 2 days ago assesses slight bleeding around the stoma when the area is cleansed, colostomy bag filled with gas, pale stoma, and a reddened area under the adhesive of the appliance. The assessment that should be reported immediately is the assessment pertaining to the:

pale stoma.

When the patient who has an order to be out of bed complains of feeling too weak to walk to the bathroom, the nurse assists the patient with urination elimination by:

placing a commode at the bedside

The nurse has assessed that a patient's stool has changed from brown to dark black and sticky. The nurse suspects:

presence of occult blood

A nurse is digitally removing a fecal impaction from a patient. The nurse should stop the procedure immediately and take corrective action if the patient's:

pulse rate decreases from 78 to 52 beats/min.

Psyllium is prescribed for the client diagnosed with a cardiac disorder to facilitate defecation and prevent straining with bowel movements. The nurse reinforces instructions to the client regarding administration of the medication. Which statement by the client indicates an understanding of the use of the medication?

"I should mix the medication with a full glass of water." Metamucil is a bulk-forming laxative. It should be taken with a full glass of water or juice (not custard), followed by another glass of liquid. This will help prevent impaction of the medication in the stomach or small intestine. Both fiber in the diet and fluid intake should not be decreased unless specifically prescribed by the primary health care provider.

A patient who is badly constipated has just received an oil retention enema. The nurse encourages this patient to try to hold the enema for at least how long before trying to have a bowel movement?

20 minutes

A nurse should notify the physician if:

24-hour urine output is 700 mL. Average hourly urine output is 30 mL, therefore 700 mL in a 24 hour period is abnormal because it averages to less than 30 mL/hour. The remaining options reflect urine output within normal range for a 24-hour period.

A nurse is monitoring bowel elimination of a patient who has a history of constipation. The nurse implements measures to assist with bowel elimination if the patient has not had a bowel movement within how many days?

3

The nurse is monitoring an older client suspected of having a urinary tract infection (UTI) for signs of infection. Which sign/symptom is likely to present first?

Confusion In an older client, the only symptom of a UTI may be something as vague as increasing mental confusion or frequent unexplained falls. Frequency and urgency may commonly occur in an older client, and fever can be associated with a variety of conditions.

A client hospitalized with urolithiasis has a sudden significant decrease in urine output. The nurse would perform which action?

Tell the client to drink increased fluids. A sudden significant decrease in urine output to either oliguria or anuria represents obstruction of the urinary tract, usually at the bladder neck or urethra. This represents a medical emergency requiring prompt treatment to preserve kidney function. In this instance, the nurse would notify the registered nurse, who would call the primary health care provider to report the findings immediately. There are no data in the question to indicate that a Foley catheter is present. Obtaining a urine-specific gravity will not relieve the obstruction. Telling the client to increase fluid intake is incorrect. Additionally, if an obstruction is present, increasing fluids can cause hydronephrosis.

The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse asks the client to assume a modified left lateral recumbent position. The nurse explains that this positioning is preferred because of which reason?

The enema will flow into the bowel easily When administering an enema, the client is placed in a modified left lateral recumbent position so that the enema solution can flow by gravity in the natural direction of the colon. The anatomy of the colon consists of ascending on the right, transverse across, with descending on the left leading to the sigmoid and rectum. If the client lies on the left side, the enema solution will flow easily into the bowel. The hand dominance of the nurse is not a factor. The nurse assists the client to relax the rectal sphincter by asking the client to take a deep breath. The nurse assists the client to retain the enema solution by administering the enema slowly. The nurse should also use teach-back to determine client's understanding about the reason for the enema.

A patient who has started antibiotic therapy is having diarrhea as a side effect of the medication. The nurse should encourage the patient to eat:

yogurt.