325 Gastrointestinal System

9. a nurse determines that the teaching about a guaiac test of stool is understood when the client states that it identifies the presence of which of the following? 1. ova and parasites 2. hidden blood 3. bacteria 4. bile

2. hidden blood

22. which should the nurse do before collecting a stool sample for occult blood? 1. plan to collect the first specimen of the day 2. obtain a sterile specimen container 3. wash the clients perineal area 4. ask the client to void

4. ask the client to void

30. a client is experiencing constipation. which independent nursing action facilitates defecation of a hard stool? select all that apply applying a lubricant to the anus providing a sitz bath after defecation instilling a warm mineral oil into the rectum placing a warm, wet washcloth against the perianal area encouraging the client to rock forward and back while defecation

applying a lubricant to the anus placing a warm, wet washcloth against the perianal area encouraging the client to rock forward and back while defecation

37. which statement by a client with diverticulosis alerts the nurse that the client needs additional health teaching? select all that apply "i should avoid eating high-fiber cereal" "i sit on the toilet for 10 minutes after breakfast every day" "I am going to drink 8 glasses of water a day when I get home" "I should hold my breath and bear down when having a bowel movement" "I like to massage my lower abdomen when I'm trying to have a bowel movement"

"i should avoid eating high-fiber cereal" "I should hold my breath and bear down when having a bowel movement"

5. a nurse is caring for a client who is experiencing diarrhea. which physiological response to diarrhea should the nurse be most concerned about? 1. dehydration 2. malnutrition 3. excoriated skin 4. urinary incontinence

1. dehydration

3. A nurse discourages a client from straining excessively when attempting to have a bowel movement. Which undesirable physiological response is the primary reason why straining on defecation should be avoided? 1. dysrythmia 2. incontinence 3. fecal impaction 4. rectal hemorrhod

1. dysrythmia

16. which outcome of the options presented is most appropriate for a client with perceived constipation? 1. have a bowel movement without the use of laxative 2. explain the rationale for the use of laxative 3. drink 8 glasses of water per day 4. defecate every day

1. have a bowel movement without the use of laxative

6. a nurse identifies that a client's colostomy stoma is pale. which should the nurse do? 1. notify the surgeon 2. listen for bowel sounds 3. wash the area with warm water 4. gently massage around the stoma

1. notify the surgeon

15. a nurse is teaching a client how to irrigate a colostomy. the client asks, "why is it necessary to use the cone attachment to the irrigation catheter?" what information should the nurse include in a response to this question? 1. stops enema solution from flowing out of the bowel during the procedure 2. prevents prolapse of the bowel during evacuation of the solution 3. dilates the stoma so that the enema tube can be inserted 4. facilitates the elimination of drainage from the colon

1. stops enema solution from flowing out of the bowel during the procedure

13. a nurse identifies that a client has tarry stools. which problem should the nurse conclude that the client is experiencing? 1. upper gastrointestinal bleeding 2. pancreatic dysfunction 3. lactulose intolerance 4. inadequate bile salts

1. upper gastrointestinal bleeding

12. a nurse is teaching a client with a history of constipation about the excessive use of laxatives. which effect of laxatives should the nurse include as the primary reason why their use should be avoided? 1. weakens the natural response to defecation 2. results in distention of the intestines 3. causes abdominal discomfort 4. precipitates incontinence

1. weakens the natural response to defecation

32, a primary health care provider prescribes docusate solution in liquid form for a client who is constipated but has difficulty swallowing tablets. the prescription is for 200 mg daily to be divided into two doses, one in the am and one at hour of sleep. the package insert states that there is 50 mg/5ml. how much solution of docusate sodium should the nurse administer per dose?

10 mL

17. which action is important for the nurse to teach clients about the intake of bran to facilitate defecation? 1. ingest 3 tablespoons of bran each morning 2. drink at least 8 glasses of fluid daily when taking bran 3. attempt a bowel movement right after ingesting the bran 4. take a cathartic daily that will supplement the action of bran

2. drink at least 8 glasses of fluid daily when taking bran

11. which client statement supports the nurse's conclusion that a client understands the need to reestablish bowel flora after a week of diarrhea? 1. I must wean myself off of the antibiotics one day after my temperature is normal 2. i should eat a container of yogurt each day for a few days 3. i have to add rice to my diet in one meal each day 4. i ought to drink eight glasses of water a day

2. i should eat a container of yogurt each day for a few days

23. a nurse performs a physical assessment of a newly admitted client who is incontinent of stool. for which characteristics related to bowel incontinence should the nurse assess the client? 1. frequent soft stools 2. involuntary passage of stool 3. impaired and sphincter control 4. greenish-yellow color of the stool

2. involuntary passage of stool

19. which word is specific regarding how a soapsuds enema works on the mucosa of the bowel? 1. dilating 2. irritating 3. softening 4. lubrication

2. irritating

4. a school nurse is planning a health class about bodily functions. which information should be included regarding the purpose of mucus in the gastrointestinal tract? 1. activates digestive enzymes 2. protects the gastric mucosa 3. enhances gastric acidity 4. emulsifies fat

2. protects the gastric mucosa

24. a nurse is collecting a bowel elimination history from a newly admitted client with a medical diagnosis of possible bowel obstruction. which question takes priority? 1. do you use anything to help you move your bowels 2. when was the last time you moved your bowels 3. what color are your usual bowel movements 4. how often do you have a bowel movement

2. when was the last time you moved your bowels

7. a nurse is caring for a group of clients. which client factor should the nurse identify as placing a client at risk for bowel incontinence? 1. being ninety years old 2. taking a sedative for sleep 3. disoriented to time, place, and person 4. receiving multiple antibiotic medications

3. disoriented to time, place, and person

1. Which statement by a client with an ileostomy alerts the nurse to the need for further education? 1. I dont expect to have much of a problem with fecal odor from the stoma 2. i will have to take special precautions to protect my skin around the stoma 3. i am going to have a bowel movement every morning when i irrigate the stoma 4. i should avoid gas-forming foods like beans to limit funny noises from the stoma

3. i am going to have a bowel movement every morning when i irrigate the stoma

18. a primary health care provider prescribes a tap-water enema for a client. the client asks about the purpose of the enema. which specific information about the purpose of a tap-water enema should be included in the nurse's response? 1. it reduces abdominal gas 2. it drains the urinary bladder 3. it empties the bowel of stool 4. it limits nausea and vomitting

3. it empties the bowel of stool

26. a nurse is implementing a prescribed bowel preparation for a client who is scheduled for a colonoscopy. which is the most serious consequence that is prevented by an effective bowel preparation? 1. psychological stress 2. wasted expense 3. misdiagnosis 4. discomfort

3. misdiagnosis

10. A nurse must collect a specimen for the presence of pinworms. Which action is essential to ensure accuracy of the specimen? 1. press the sticky side of nonfrosted cellophane tape across the anus before the client goes to bed at night 2. insert a swab beyond the internal anal sphincter and rotate it gently while removing it from the anus 3. perform the procedure the first thing in the morning before the first bowel movement 4. wash the rectal area gently with soap and water before performing the procedure

3. perform the procedure the first thing in the morning before the first bowel movement

20. a nurse is caring for a client with an intestinal stoma. which intervention is most important 1. cleaning the stoma with clean water 2. spraying an air-freshening deodorant in the room 3. selecting a bag with an appropriate size stomal opening 4. wearing sterile, nonlatex gloves when caring for the stoma

3. selecting a bag with an appropriate size stomal opening

8. a client is admitted with lower gastrointestinal tract bleeding. which characteristics of the client's stool should the nurse assess for that supports this medical diagnosis? 1. tarry stool 2. orange stool 3. green mucoid stool 4. bright red-tinged stool

4. bright red-tinged stool

27. a nurse is assessing a client who has a distended abdomen resulting from flatulence. the client has a prescription for a regular diet and an activity prescription for "out of bed". Which can the nurse do to promote passage of the intestinal gas? 1. instruct the client to increase the amount of fluid intake 2. suggest that the client avoid cruciferous foods 3. obtain a prescription for a laxative 4. encourage the client to ambulate

4. encourage the client to ambulate

25. while providing a health history, the client tells the nurse, "i have gastroesophageal reflux disease" which most serious consequence associated with this disorder should the nurse anticipate this client may develop? 1. diarrhea 2. heartburn 3. gastric fullness 4. esophageal erosion

4. esophageal erosion

14. a nurse is teaching a client with a cardiac condition to avoid the valsalva maneuver. which should the nurse teach the client to do? 1. eat rice several times a week 2. take a cathartic on a regular basis 3. attempt to have a bowel movement every day 4. exhale while contracting the abdominal muscles

4. exhale while contracting the abdominal muscles

2. a primary health care provider prescribes a return-flow enema (harris flush/ harris drip) for an adult client with flatulence. When preparing to administer this enema, the nurse compares the steps of a return-flow enema with those for cleansing enemas. Which nursing intervention is unique to a return-flow enema? 1. lubricate the last 2 inches of the rectal tube 2. insert the rectal tube about 4 inches into the anus 3. raise the solution container about 12 inches above the anus 4. lower the solution container after instilling about 150mL of solution

4. lower the solution container after instilling about 150mL of solution

21. Which should the nurse do when administering a small-volume hypertonic enema to an adult? 1. insert the rectal tube 1 to 1.5 inches into the anal canal 2. position the enema bottle 12 inches above the level of the clients anus 3. direct the rectal tube toward the vertebrae as it is inserted into the rectum 4. maintain the compression of the enema container until after withdrawing the tube

4. maintain the compression of the enema container until after withdrawing the tube

36. a nurse is caring for a group of clients with a variety of gastrointestinal problems. which of the following can cause both diarrhea and constipation? select all that apply inability to perceive bowel cues cancer of the large intestine side effects of medications high-solute tube feedings increase metabolic rate

cancer of the large intestine side effects of medications

39. a client had a colonscopy with several polyps excised for biopsies. the nurse teaches the client routine post-procedure expectations. which of the following should the nurse instruct the client to report to the primary health-care provider? select all that apply intermittent passage of gas from the anus continuous abdominal cramping some abdominal bloating minimal rectal bleeding mild fatigue

continuous abdominal cramping

31. A client is place on a therapeutic regimen of an anticoagulant because of a history of deep vein thrombosis and an antihypertenstive for an elevated blood pressure. two weeks later, the client tells the nurse about eating a clove of garlic daily along with the prescribed medications. in addition to informing the primary health care provider about the clients intake of garlic, what should the nurse teach the client about the clients medication regiment and the intake of garlic? select all that apply avoid taking garlic because it can cause excessive amounts of hemoglobin in your body discontinue the intake of garlic 2 weeks before any surgery to prevent hemorrhage the risk of bruising and bleeding increases when garlic is taken concurrently with an anticoagulant garlic increases the antihypertensive effects of medication taken to treat an elevated blood pressure stop taking garlic and notify the doctor immediately if you experience a rash, itching, sever dizziness, trouble breathing, or swelling of the face, tongue, or throat

discontinue the intake of garlic 2 weeks before any surgery to prevent hemorrhage the risk of bruising and bleeding increases when garlic is taken concurrently with an anticoagulant stop taking garlic and notify the doctor immediately if you experience a rash, itching, sever dizziness, trouble breathing, or swelling of the face, tongue, or throat

40. a nurse is to administer an oil-retention enema, a tap-water enema, and a return-flow enema to three different clients. which of the following should be performed with all three enemas? select all that apply use betwen 500 and 1,000 mL of solution place the client in the left side-lying position use water-soluble jelly to lubricate the tip of the rectal probe pull the curtain around the client's bed and drape the client hold the enema solution a minimum of 12 inches above the anus

place the client in the left side-lying position use water-soluble jelly to lubricate the tip of the rectal probe pull the curtain around the client's bed and drape the client

33. a nurse is assisting a client with a regular bedpan. which nursing action is essential. select all that apply position the client slightly off the back edge of the bedpan fold the top linen out of the way when putting the client on the bedpan remain outside the curtains of the bed until the client is done using the bedpan elevate the head of the bed to the fowler position after the client is on the bedpan raise the side rails on both sides of the bed after the client is positioned on the bed pain

remain outside the curtains of the bed until the client is done using the bedpan elevate the head of the bed to the fowler position after the client is on the bedpan raise the side rails on both sides of the bed after the client is positioned on the bed pain

28. a nurse should use a fracture bedpan for clients with which conditions? select all that apply below the knee amputation peripheral vascular disease spinal cord injury dementia obesity

spinal cord injury

34. a nurse is providing dietary teaching to a client with acute diverticulitis who has a prescription for a low-fiber diet. which food selected by the client indicates that the dietary teaching was understood? select all that apply white rice split peas soft tofu turkey pasta

white rice soft tofu turkey pasta