Chapter 42: Lower Gastrointestinal Problems

hen evaluating the patient's understanding about the care of the ileostomy, which statement by the patient indicates the patient needs more teaching?

"I will be able to regulate when I have stools." Rationale: An ileostomy is in the ileum and drains liquid stool frequently, unlike a colostomy, which has more formed stool the farther distal the ostomy is in the colon. The ileostomy pouch is usually worn for 4 to 7 days or until it leaks. It must be changed immediately if it leaks because the drainage is very irritating to the skin. To avoid obstruction, popcorn, dried fruit, coconut, mushrooms, olives, stringy vegetables, food with skin, and meats with casings must be chewed extremely well before swallowing because of the narrow diameter of the ileostomy lumen.

The nurse is preparing to administer a dose of bisacodyl to a patient with constipation and the patient asks how it will work. What is the best response by the nurse?

"It will increase peristalsis by stimulating nerves in the colon wall." Rationale: Bisacodyl is a stimulant laxative that aids in producing a bowel movement by irritating the colon wall and stimulating enteric nerves. Fiber and bulk-forming drugs increase bulk in the stool. Water and stool softeners soften feces, and saline and osmotic solutions cause fluid retention in the intestinal tract.

The nurse is preparing to administer famotidine to a patient after a laparotomy. The patient states they do not have heartburn. What response by the nurse would be the most appropriate?

"It will reduce the amount of acid in the stomach while you are not eating." Rationale: Famotidine is an H2-receptor antagonist that inhibits gastric HCl secretion and thus minimizes damage to gastric mucosa while the patient is not eating a regular diet after surgery. Famotidine does not prevent air from accumulating in the stomach or stop the stomach from bleeding. Heartburn is not a side effect of general anesthesia.

The nurse is preparing to insert a nasogastric (NG) tube into a patient with a suspected small intestinal obstruction that is vomiting. The patient asks the nurse why this procedure is necessary. What response by the nurse is most appropriate?

"The tube will help to drain the stomach contents and prevent further vomiting." Rationale: The NG tube is used to decompress the stomach by draining stomach contents and thereby prevent further vomiting. The NG tube will not push past the blocked area. Potential surgery is not currently indicated. The location of the obstruction will determine the type of fluid to use, not measure the amount of stomach contents.

Four hours after a bowel resection, a 74-yr-old male patient with a nasogastric tube to suction reports nausea and abdominal distention. What should be the nurse's first action?

. Check for tube placement and reposition it Repositioning the tube will frequently facilitate drainage. Because this is a common occurrence, it is not appropriate to notify the health care provider unless other interventions do not resolve the problem. Information about the presence or absence of bowel sounds will not be helpful in improving drainage. Removing the tube and replacing it are unnecessarily traumatic to the patient, so that would only be done if the tube was completely occluded.

After having frequent diarrhea and a weight loss of 10 lb (4.5 kg) over 2 months, a patient has a new diagnosis of Crohn's disease. What should the nurse plan to teach the patient?

. Medication use Medications are used to induce and maintain remission in patients with inflammatory bowel disease (IBD). Decreased activity level is indicated only if the patient has severe fatigue and weakness. Fluids are needed to prevent dehydration. There is no advantage to enteral feedings.

Which diet choice by the patient with an acute exacerbation of inflammatory bowel disease (IBD) indicates a need for more teaching?

. Oatmeal with cream During acute exacerbations of IBD, the patient should avoid high-fiber foods such as whole grains. High-fat foods also may cause diarrhea in some patients. The other choices are low residue and would be appropriate for this patient.

A patient is given a bisacodyl suppository and asks the nurse how long it will take to work. What is the best response by the nurse?

15 to 60 minutes Rationale: Bisacodyl suppositories usually are effective within 15 to 60 minutes of administration, so the nurse should plan accordingly to assist the patient to use the bedpan or commode.

A patient with suspected bowel obstruction had a nasogastric tube inserted at 4:00 AM. The nurse shares in the morning report that the day shift staff should check the tube for patency at what times?

8:00 AM, 12:00 PM, and 4:00 PM Rationale: A nasogastric tube should be checked for patency routinely at 4-hour intervals. Thus if the tube were inserted at 4:00 AM, it would be due to be checked at 8:00 AM, 12:00 PM, and 4:00 PM.

The nurse identifies that which patient is at highest risk for developing colon cancer?

A 32-yr-old woman with a 12-year history of ulcerative colitis Rationale: Risk for colon cancer includes personal history of inflammatory bowel disease (especially ulcerative colitis for longer than 10 years); obesity; family (first-degree relative) or personal history of colorectal cancer, adenomatous polyposis, or hereditary nonpolyposis colorectal cancer syndrome; eating red meat; cigarette use; and drinking alcohol.

A patient is planned for discharge home today after ostomy surgery for colon cancer. The nurse should assign the patient to which staff member?

An RN with 6 months of experience on the surgical unit Rationale: The patient needs ostomy care directions and reinforcement at discharge and should be assigned to a registered nurse with experience in providing discharge teaching for ostomy care. Teaching should not be delegated to a LPN/VN or UAP.

Which clinical manifestations of inflammatory bowel disease are common to both patients with ulcerative colitis (UC) and Crohn's disease? (Select all that apply)

Bloody, diarrhea stools Cramping abdominal pain Rationale: Manifestations of UC and Crohn's disease include bloody diarrhea, cramping abdominal pain, and nutritional disorders. Intestinal lesions associated with UC are usually restricted to the rectum before moving into the colon. Lesions that penetrate the intestine or cause strictures are characteristic of Crohn's disease.

The nurse is preparing to administer a scheduled dose of docusate sodium when the patient reports an episode of loose stool and does not want to take the medication. What is the appropriate action by the nurse?

Chart the dose as not given on the medical record and explain in the nursing progress notes. Rationale: Whenever a patient refuses medication, the dose should be charted as not given with an explanation of the reason documented in the nursing progress notes. In this instance, the refusal indicates good judgment by the patient, and the patient should not be encouraged to take it today.

The nurse asks a patient scheduled for colectomy to sign the operative permit as directed in the provider's preoperative orders. The patient states that the provider has not explained very well what is involved in the surgical procedure. What is the most appropriate action by the nurse?

Delay the patient's signature on the consent and notify the provider about the conversation with the patient. Rationale: The patient should not be asked to sign a consent form unless the procedure has been explained to the satisfaction of the patient. The nurse should notify the provider, who has the responsibility for obtaining consent.

The nurse is admitting a patient with severe dehydration and frequent watery diarrhea. A 10-day outpatient course of antibiotic therapy for bacterial pneumonia has just been completed. What is the most important for the nurse to take which action?

Don gloves and gown before entering the patient's room. Rationale: Clostridium difficile is an antibiotic-associated diarrhea transmitted by contact, and the spores are extremely difficult to kill. Patients with suspected or confirmed infection with C. difficile should be placed in a private room, and gloves and gowns should be worn by visitors and health care providers. Alcohol-based hand cleaners and ammonia-based disinfectants are ineffective and do not kill all the spores. Equipment cannot be shared with other patients, and a disposable stethoscope and individual patient thermometer are kept in the room. Objects should be disinfected with a 10% solution of household bleach.

When teaching the patient about the diet for diverticular disease, which foods should the nurse recommend?

Dried beans, All Bran (100%) cereal, and raspberries Rationale: A high-fiber diet is recommended for diverticular disease. Dried beans, All Bran (100%) cereal, and raspberries all have higher amounts of fiber than white bread, cheese, green beans, fresh tomatoes, pears, corn flakes, oranges, baked potatoes, and raw carrots.

After an exploratory laparotomy, a patient on a clear liquid diet reports severe gas pains and abdominal distention. Which action by the nurse is most appropriate?

Encourage the patient to ambulate as ordered. Rationale: Swallowed air and reduced peristalsis after surgery can result in abdominal distention and gas pains. Early ambulation helps restore peristalsis and eliminate flatus and gas pain. Medications used to reduce gas pain include metoclopramide, which stimulates peristalsis. A heating pad can help to alleviate some of the pain and help make the patient more comfortable. There is no need for the patient to return to NPO status. Drinking ginger ale may be helpful.

A patient after a stroke who primarily uses a wheelchair for mobility has developed diarrhea with fecal incontinence. What is a priority assessment by the nurse?

Fecal impaction Rationale: Patients with limited mobility are at risk for fecal impactions caused by constipation that may lead to liquid stool leaking around the hardened impacted feces, so assessing for fecal impaction is the priority. Perineal hygiene can be assessed at the same time. Assessing the dietary fiber and fluid intake and antidiarrheal agent use will be assessed and considered next.

patient is admitted to the emergency department after a motor vehicle crash with suspected abdominal trauma. What assessment finding by the nurse is of highest priority?

Firmly distended abdomen Rationale: Manifestations of abdominal trauma are guarding and splinting of the abdominal wall; a hard, distended abdomen (indicating possible intraabdominal bleeding); decreased or absent bowel sounds; contusions, abrasions, or bruising over the abdomen; abdominal pain; pain over the scapula; hematemesis or hematuria; and signs of hypovolemic shock (tachycardia and decreased blood pressure).

he nurse is caring for a patient admitted with a suspected bowel obstruction. The nurse auscultating the abdomen listens for which type of bowel sounds that are consistent with the patient's clinical picture?

High-pitched and hyperactive above the area of obstruction Rationale: Early in intestinal obstruction, the patient's bowel sounds are hyperactive and high pitched, sometimes referred to as "tinkling," above the level of the obstruction. This occurs because peristaltic action increases to "push past" the area of obstruction. As the obstruction becomes complete, bowel sounds decrease and finally become absent.

he nurse is developing a plan of care for a patient with an abdominal mass and suspected bowel obstruction. Which factor in the patient's history does the nurse recognize as increasing the patient's risk for colorectal cancer?

History of colorectal polyps Rationale: A history of colorectal polyps places this patient at risk for colorectal cancer. This tissue can degenerate over time and become malignant. Osteoarthritis, lactose intolerance, and the use of herbs do not pose additional risk to the patient.

What information would have the highest priority for the nurse to include in preoperative teaching for a patient scheduled for an exploratory laparotomy?

How to deep breathe and cough Rationale: Because anesthesia, an abdominal incision, and pain can impair the patient's respiratory status in the postoperative period, it is of high priority to teach the patient to cough and deep breathe. Otherwise, the patient could develop atelectasis and pneumonia, which would delay early recovery from surgery and hospital discharge. Care for the wound and location and care of the drains will be briefly discussed preoperatively but will be done again with higher priority after surgery. Knowing which drugs will be used during surgery may not be meaningful to the patient and should be reviewed with the patient by the anesthesiologist.

Two days after a bowel resection for an abdominal mass, a patient reports gas pains and abdominal distention. The nurse plans care for the patient based on the knowledge that the symptoms are occurring as a result what event?

Impaired peristalsis Rationale: Until peristalsis returns to normal after anesthesia, the patient may experience slowed gastrointestinal motility, leading to gas pains and abdominal distention. Irritation of the bowel, nasogastric suctioning, and inflammation of the surgical site do not cause gas pains or abdominal distention.

A hospitalized patient has just been diagnosed with diarrhea due to C. difficile. Which nursing interventions should be included in the patient's plan of care? (Select all that apply.)

Initiate contact isolation precautions. Teach any visitors to wear gloves and gowns. Disinfect the room with 10% bleach solution as needed. Rationale: Initiation of contact isolation precautions must be done immediately with a patient with C. difficile, which includes washing hands with soap and water before and after patient or bodily fluid contact. Alcohol-based sanitizers are ineffective. Visitors need to be taught to wear gloves and gowns and wash hands. A clear liquid diet is not necessary. The room will be disinfected with 10% bleach solution when the patient is dismissed and may be done periodically during the patient's stay, depending on the agency policy.

The nurse is administering a cathartic agent to a patient with renal insufficiency. Which order will the nurse question?

Magnesium hydroxide Rationale: Milk of magnesia may cause hypermagnesemia in patients with renal insufficiency. The nurse should question this order with the health care provider. Bisacodyl, lubiprostone, and cascara sagrada are safe to use in patients with renal insufficiency as long as the patient is not currently dehydrated.

The nurse is conducting discharge teaching for a patient with metastatic lung cancer who was admitted with a bowel impaction. Which instructions would be most helpful to prevent further episodes of constipation?

Maintain a high intake of fluid and fiber in the diet. Rationale: Increased fluid intake and a high-fiber diet reduce the incidence of constipation caused by immobility, medications, and other factors. Fluid and fiber provide bulk that in turn increases peristalsis and bowel motility. Analgesics taken for lung cancer probably cannot be discontinued. Eating several small meals per day and position do not facilitate bowel motility.

he nurse should administer an as-needed dose of magnesium citrate after noting what information when reviewing a patient's medical record?

No bowel movement for 3 days Rationale: Magnesium citrate is an osmotic laxative that produces a soft, semisolid stool usually within 15 minutes to 3 hours. This medication would benefit the patient who has not had a bowel movement for 3 days. It would not be given for abdominal pain and bloating, decreased appetite, or signs of hypomagnesemia.

A patient with an intestinal obstruction has a nasogastric (NG) tube to suction but reports of nausea and abdominal distention. The nurse irrigates the tube as necessary as ordered, but the irrigating fluid does not return. What should be the priority action by the nurse?

Reposition the tube and check for placement. Rationale: The tube may be resting against the stomach wall. The first action by the nurse is to reposition the tube and check it again for placement. The provider does not need to be notified unless the nurse cannot restore the tube function. The patient does not have bowel sounds, which is why the NG tube is in place. The NG tube would not be removed and replaced unless it was no longer in the stomach or the obstruction of the tube could not be relieved.

A patient with ulcerative colitis is scheduled for a colon resection with placement of an ostomy. The nurse should plan to include which prescribed measure in the preoperative preparation

Selecting the stoma site Rationale: Care that is unique to ostomy surgery includes selecting the best site for the stoma. Instructions to irrigate the colostomy and where to purchase ostomy supplies will be done postoperatively. A clear liquid diet will be used the day before surgery with the bowel cleansing.

The nurse is preparing to administer a daily dose of docusate sodium to a patient that will continue taking it after discharge. What information should the nurse provide to the patient to optimize the outcome of the medication?

Take each dose with a full glass of water or other liquid. Rationale: Docusate lowers the surface tension of stool, permitting water and fats to penetrate and soften the stool for easier passage. The patient should take the dose with a full glass of water and should increase overall fluid intake, if able, to enhance effectiveness of the medication. Dietary fiber intake should be a minimum of 20 g daily to prevent constipation. Mineral oil and extra salt are not recommended.

A patient with ulcerative colitis is scheduled for a total proctocolectomy with permanent ileostomy. The wound, ostomy, and continence nurse is selecting the site where the ostomy will be placed. What should be included in site consideration?

The patient must be able to see the site. Rationale: In selection of the ostomy site, the WOC nurse will want a site visible to the patient so the patient can take care of it, within the rectus muscle to avoid hernias, and on a flat surface to more easily create a good seal with the drainage bag. Care should be taken to avoid skin creases, scars, and belt lines, which can interfere with the adherence of the appliance.

Which patient statement indicates that the nurse's teaching about sulfasalazine (Azulfidine) for ulcerative colitis has been effective?

a. "I should apply sunscreen before going outdoors." Sulfasalazine may cause photosensitivity in some patients. It is not used to treat infections. Sulfasalazine does not reduce immune function. Unlike corticosteroids, tapering of sulfasalazine is not needed.

A patient with a new ileostomy asks how much it will drain. How many cups of drainage per day should the nurse explain for the patient to expect?

a. 2 After the proximal small bowel adapts to reabsorb more fluid, the average amount of ileostomy drainage is about 500 mL daily. One cup is about 240 mL.

Which patient should the nurse assess first after receiving change-of-shift report?

a. A 30-yr-old patient who has a distended abdomen and tachycardia The patient's abdominal distention and tachycardia suggest hypovolemic shock caused by problems such as peritonitis or intestinal obstruction, which will require rapid intervention. The other patients should be assessed as quickly as possible, but the data do not indicate any life-threatening complications associated with their diagnoses.

What should the nurse admitting a patient with acute diverticulitis plan for initial care?

a. Administer IV fluids. A patient with acute diverticulitis will be NPO and given parenteral fluids. A diet high in fiber and fluids will be implemented before discharge. Bulk-forming laxatives, rather than stool softeners, are usually given. These will be implemented later in the hospitalization. The patient with acute diverticulitis will not have enemas or a colonoscopy because of the risk for perforation and peritonitis.

A patient calls the clinic to report a new onset of severe diarrhea. What should the nurse anticipate that the patient will need to do?

a. Collect a stool specimen. Acute diarrhea is usually caused by an infectious process, so stool specimens are obtained for culture and examined for parasites or white blood cells. There is no indication that the patient needs a colonoscopy, blood cultures, or a barium enema.

Which nursing action will be included in the plan of care for a 25-yr-old male patient with a new diagnosis of irritable bowel syndrome (IBS)

a. Encourage the patient to express concerns and ask questions about IBS. Because psychologic and emotional factors can affect the symptoms for IBS, encouraging the patient to discuss emotions and ask questions is an important intervention. Alosetron has serious side effects and is used only for female patients who have not responded to other therapies. Although yogurt may be beneficial, milk is avoided because lactose intoler

A patient with Crohn's disease who is taking infliximab (Remicade) calls the nurse in the outpatient clinic about new symptoms. Which symptom is most important to communicate to the health care provider?

a. Fever Since infliximab suppresses the immune response, rapid treatment of infection is essential. Nausea, joint pain, and headache are common side effects of the medication, but they do not indicate any potentially life-threatening complications

A young woman with Crohn's disease develops a fever and symptoms of a urinary tract infection (UTI) with tan, fecal-smelling urine. What information will the nurse add to a general teaching plan about UTIs in order to individualize the teaching for this patient?

a. Fistulas can form between the bowel and bladder Fistulas between the bowel and bladder occur in Crohn's disease and can lead to UTI. Teaching for UTI prevention in general includes good hygiene, adequate fluid intake, and voiding before and after intercourse.

A patient is awaiting surgery for acute peritonitis. Which action will the nurse plan to include in the preoperative care?

a. Position patient with the knees flexed. There is less peritoneal irritation with the knees flexed, which will help decrease pain. Opioids and sedatives are typically given to control pain and anxiety. Preoperative patients with peritonitis are given IV fluids for hydration. Deep breathing and coughing will increase the patient's discomfort.

Which prescribed intervention for a patient with chronic short bowel syndrome should the nurse question?

a. Senna 1 tablet daily Patients with short bowel syndrome have diarrhea because of decreased nutrient and fluid absorption and would not need stimulant laxatives. Iron supplements are used to prevent iron-deficiency anemia, bulk-forming laxatives help make stools less watery, and opioid antidiarrheal drugs are helpful in slowing intestinal transit time.

The nurse is admitting a 67-yr-old patient with new-onset steatorrhea. Which question is most important for the nurse to ask?

b. "Have you noticed a recent weight loss?" Although all the questions provide useful information, it is most important to determine if the patient has an imbalance in nutrition because of the steatorrhea.

After change-of-shift report, which patient should the nurse assess first?

b. A 30-yr-old female patient with a femoral hernia who has abdominal pain and vomiting Pain and vomiting with a femoral hernia suggest strangulation, which will require emergency surgery. All the other patients require assessment or care but have less urgent problems.

After a total proctocolectomy and permanent ileostomy, the patient tells the nurse, "I cannot manage all this. I don't want to look at the stoma." What action should the nurse take?

b. Ask the patient about the concerns with stoma management Encouraging the patient to share concerns assists in helping the patient adjust to the body changes. Acknowledgment of the patient's feelings and concerns is important rather than offering false reassurance. Because the patient indicates that the feelings about the ostomy are the reason for the difficulty with the many changes, development of a detailed ostomy care plan will not improve the patient's ability to manage the ostomy. Although detailed ostomy teaching could be postponed, the nurse should begin to offer teaching about some aspects of living with an ostomy.

Which care activity for a patient with a paralytic ileus is appropriate for the registered nurse (RN) to delegate to unlicensed assistive personnel (UAP)?

b. Brushing the teeth and tongue UAP education and scope of practice include patient hygiene such as oral care. The other actions require education and scope of practice appropriate to the RN.

Which information will the nurse include when teaching a patient how to avoid chronic constipation? (Select all that apply.)

b. Bulk-forming laxatives are an excellent source of fiber. c. Walking or cycling frequently will help bowel motility. d. A good time for a bowel movement may be after breakfast. e. Some over-the-counter (OTC) medications cause constipation Stimulant and saline laxatives should be used infrequently. Use of bulk-forming laxatives, regular early morning timing of defecation, regular exercise, and avoiding many OTC medications will help the patient avoid constipation.

What should the nurse preparing for the annual physical exam of a 45-yr-old man plan to teach the patient about?

b. Colonoscopy At age 45 years, persons with an average risk for colorectal cancer (CRC) should begin screening for CRC. Colonoscopy is the gold standard for CRC screening. The other diagnostic tests are not recommended as part of a routine annual physical exam at age 45 years.

A patient being admitted with an acute exacerbation of ulcerative colitis reports crampy abdominal pain and passing 15 bloody stools a day. What should the nurse include in the plan of care?

b. Discontinue the patient's oral food intake. An initial therapy for an acute exacerbation of inflammatory bowel disease (IBD) is to rest the bowel by making the patient NPO. Metoclopramide increases peristalsis and will worsen symptoms. Cobalamin (vitamin B12) is absorbed in the ileum, which is not affected by ulcerative colitis. Although total colectomy is needed for some patients, there is no indication that this patient is a candidate.

A patient reports gas pains and abdominal distention 2 days after a small bowel resection. Which nursing action should the nurse take?

b. Encourage the patient to ambulate. Ambulation will improve peristalsis and help the patient eliminate flatus and reduce gas pain. A mineral oil retention enema is helpful for constipation with hard stool. A return-flow enema might be used to relieve persistent gas pains. Morphine will further reduce peristalsis. Promethazine is used as an antiemetic rather than to decrease gas pains or distention.

Which nursing action will the nurse include in the plan of care for a patient admitted with an exacerbation of inflammatory bowel disease (IBD)?

b. Monitor stools for blood. Because anemia or hemorrhage may occur with IBD, stools should be assessed for the presence of blood. The other actions would not be appropriate for the patient with IBD. Dietary fiber may increase gastrointestinal motility and exacerbate the diarrhea, severe fatigue is common with IBD exacerbations, and dehydration may occur.

A patient preparing to undergo a colon resection for cancer of the colon asks about the elevated carcinoembryonic antigen (CEA) test result. What should the nurse explain as the reason for the test?

b. Monitor the tumor status after surgery CEA is used to monitor for cancer recurrence after surgery. CEA levels do not help to determine whether there is metastasis of the cancer. Confirmation of the diagnosis is made based on the biopsy. Chemotherapy use is based on factors other than CEA.

A patient with blunt abdominal trauma from a motor vehicle crash undergoes peritoneal lavage. If the lavage returns brown fecal drainage, which action will the nurse plan to take next?

b. Prepare the patient for surgery. Return of brown drainage and fecal material suggests perforation of the bowel and the need for immediate surgery. Auscultation of bowel sounds, checking the temperature, and obtaining information about the accident are appropriate actions, but the priority is to prepare to send the patient for emergency surgery.

A 74-yr-old male patient tells the nurse that growing old causes constipation, so he has been using a suppository to prevent constipation every morning. Which action should the nurse take first?

b. Question the patient about risk factors for constipation. The nurse's initial action should be further assessment of the patient for risk factors for constipation and for his usual bowel pattern. The other actions may be appropriate but will be based on the assessment.

A 19-yr-old patient has familial adenomatous polyposis (FAP). Which action will the nurse in the gastrointestinal clinic include in the plan of care?

b. Schedule the patient for yearly colonoscopy Patients with FAP should have annual colonoscopy starting at age 16 years and usually have total colectomy by age 25 years to avoid developing colorectal cancer. DNA analysis is used to make the diagnosis but is not needed now for this patient. Lifestyle modifications will not decrease cancer risk for this patient.

Which information obtained by the nurse interviewing a 30-yr-old male patient is most important to communicate to the health care provider?

b. The patient has noticed blood in the stools Blood in the stools is a possible clinical manifestation of colorectal cancer and requires further assessment by the health care provider. The other patient information will also be communicated to the health care provider but does not indicate an urgent need for further testing or intervention

A 22-yr-old female patient with an exacerbation of ulcerative colitis is having 15 to 20 stools daily and has excoriated perianal skin. Which patient behavior indicates that teaching regarding maintenance of skin integrity has been effective?

b. The patient uses witch hazel compresses to soothe irritation. Witch hazel compresses are suggested to reduce anal irritation and discomfort. Incontinence briefs may trap diarrhea and increase the incidence of skin breakdown. Antidiarrheal medications are not given 15 to 20 times a day. The perianal area should be washed with plain water or pH balanced cleanser after each stool.

A 33-yr-old male patient with a gunshot wound to the abdomen undergoes surgery, and a colostomy is formed as shown in the accompanying figure. Which information will be included in patient teaching?

b. This type of colostomy is usually temporary. A loop, or double-barrel stoma, is usually temporary. Stool will be expelled from the proximal stoma only. The stool from the transverse colon will be liquid and regulation through irrigations will not be possible.

A critically ill patient with sepsis is frequently incontinent of watery stools. What action by the nurse will prevent complications associated with ongoing incontinence?

b. Use a fecal management system. Fecal management systems are designed to contain loose stools and can be in place for as long as 4 weeks without causing damage to the rectum or anal sphincters. Although incontinence briefs may be helpful, unless they are changed frequently, they are likely to increase the risk for skin breakdown. Rectal tubes are avoided because of possible damage to the anal sphincter and ulceration of the rectal mucosa. A critically ill patient will not be able to tolerate getting up frequently to use the commode or bathroom.

Which information will the nurse include in teaching a patient who had a proctocolectomy and ileostomy for ulcerative colitis?

b. Use care when eating high-fiber foods to avoid obstruction of the ileum. High-fiber foods are introduced gradually and should be well chewed to avoid obstruction of the ileostomy. Patients with ileostomies lose the absorption of water in the colon and need to take in increased amounts of fluid. The pouch should be drained frequently but is changed every 5 to 7 days. The drainage from an ileostomy is liquid and continuous, so control by irrigation is not possible.

A 26-yr-old woman is being evaluated for vomiting and abdominal pain. Which question from the nurse will be most useful in determining the cause of the patient's symptoms?

c. "Can you tell me more about the pain?" A complete description of the pain provides clues about the cause of the problem. Although the nurse should ask whether the patient is pregnant to determine whether the patient might have an ectopic pregnancy and before any radiology studies are done, this information is not the most useful in determining the cause of the pain. The usual diet and elimination patterns are less helpful in determining the reason for the patient's symptoms.

A 25-yr-old male patient calls the clinic reporting diarrhea for 24 hours. Which action should the nurse take first?

c. Ask the patient to describe the stools and any associated symptoms The initial response by the nurse should be further assessment of the patient. The other responses may be appropriate, depending on what is learned in the assessment.

A patient had an abdominal-perineal resection for colon cancer. Which nursing action is most important to include in the plan of care for the day after surgery?

c. Assess the perineal drainage and incision. Because the perineal wound is at high risk for infection, the initial care is focused on assessment and care of this wound. Teaching about diet is best done closer to discharge from the hospital. There will be very little drainage into the colostomy until peristalsis returns. The patient will be encouraged to assist with the colostomy, but this is not the highest priority in the immediate postoperative period.

A 19-yr-old woman is brought to the emergency department with a knife handle protruding from her abdomen. What should the nurse do during the initial assessment of the patient?

c. Check for circulation and tissue perfusion The initial assessment is focused on determining whether the patient has hypovolemic shock. The knife should not be removed until the patient is in surgery, where bleeding can be controlled. Rovsing sign is assessed in the patient with suspected appendicitis. Assessment for bladder trauma is not part of the initial assessment.

A 72-yr-old male patient with dehydration caused by an exacerbation of ulcerative colitis is receiving 5% dextrose in normal saline at 125 mL/hour. Which assessment finding by the nurse is most important to report to the health care provider?

c. Crackles are heard halfway up the posterior chest. The presence of crackles in an older patient receiving IV fluids at a high rate suggests volume overload and a need to reduce the rate of the IV infusion. The other data will be reported but are consistent with the patient's age and diagnosis and do not require a change in the prescribed treatment.

Which activity in the care of a patient with a new colostomy could the nurse delegate to unlicensed assistive personnel (UAP)?

c. Drain and measure the output from the ostomy Draining and measuring the output from the ostomy is included in UAP education and scope of practice. The other actions should be implemented by LPNs or RNs.

A patient is admitted to the emergency department with severe abdominal pain and rebound tenderness. Vital signs include temperature 102° F (38.3° C), pulse 120 beats/min, respirations 32 breaths/min, and blood pressure (BP) 82/54 mm Hg. Which prescribed intervention should the nurse implement first?

c. Infuse a liter of lactated Ringer's solution over 30 minutes The priority for this patient is to treat the patient's hypovolemic shock with fluid infusion. The other actions should be implemented after starting the fluid infusion.

A patient in the emergency department has just been diagnosed with peritonitis from a ruptured diverticulum. Which prescribed intervention will the nurse implement first?

c. Infuse metronidazole (Flagyl) 500 mg IV. Because peritonitis can be fatal if treatment is delayed, the initial action should be to start antibiotic therapy (after any ordered cultures are obtained). The other actions can be done after antibiotic therapy is initiated.

A 76-yr-old patient with obstipation has a fecal impaction and is incontinent of liquid stool. Which action should the nurse take first?

c. Manually remove the impacted stool The initial action with a fecal impaction is manual disimpaction. The other actions will be used to prevent future constipation and impactions.

Which action will the nurse include in the plan of care for a patient who is being admitted with Clostridium difficile?

c. Place the patient in a private room on contact isolation. Because C. difficile is highly contagious, the patient should be placed in a private room, and contact precautions should be used. There is no need to restrict dairy products for this type of diarrhea. Metronidazole (Flagyl) is frequently used to treat C. difficile infections. Improper food handling and storage do not cause C. difficile.

A young adult patient is admitted to the hospital for evaluation of right lower quadrant abdominal pain with nausea and vomiting. Which action should the nurse take?

c. Suggest the patient lie on the side, flexing the right leg The patient's clinical manifestations are consistent with appendicitis. Lying still with the right leg flexed is often the most comfortable position. Checking for rebound tenderness frequently is unnecessary and uncomfortable for the patient. The patient should be NPO in case immediate surgery is needed. The patient will need to know how to cough and deep breathe postoperatively, but coughing will increase pain at this time.

After a patient has had a hemorrhoidectomy at an outpatient surgical center, which instructions will the nurse include in discharge teaching?

c. Take prescribed pain medications before you expect a bowel movement. Bowel movements may be very painful, and patients may avoid defecation unless pain medication is taken before the bowel movement. A high-residue diet will increase stool bulk and prevent constipation. Delay of bowel movements is likely to lead to constipation. Warm Sitz baths rather than ice packs are used to relieve pain and keep the surgical area clean.

Which question from the nurse would help determine if a patient's abdominal pain might indicate IBS

d. "How long have you had abdominal pain?" ANS: D One criterion for the diagnosis of irritable bowel syndrome is the presence of abdominal discomfort or pain for at least 3 months. Abdominal distention, flatulence, and food intolerance are associated with IBS but are not diagnostic criteria.

What is a likely finding in the nurse's assessment of a patient who has a large bowel obstruction?

d. Abdominal distention Abdominal distention is seen in lower intestinal obstruction. Referred back pain is not a common clinical manifestation of intestinal obstruction. Metabolic alkalosis is common in high intestinal obstruction because of the loss of HCl acid from vomiting. Projectile vomiting is associated with higher intestinal obstruction.

A 40-yr-old male patient has had a herniorrhaphy to repair an incarcerated inguinal hernia. Which patient teaching will the nurse provide before discharge?

d. Apply a scrotal support and ice to reduce swelling. A scrotal support and ice are used to reduce edema and pain. Coughing will increase pressure on the incision. Sitz baths will not relieve pain and would not be of use after this surgery. Acetaminophen can be used for postoperative pain.

Which breakfast choice indicates a patient's good understanding of information about a diet for celiac disease?

d. Corn tortilla with scrambled eggs D Avoidance of gluten-containing foods is the only treatment for celiac disease. Corn does not contain gluten, but oatmeal and wheat do.

A patient is transferred from the recovery room to a surgical unit after a transverse colostomy. The nurse observes the stoma to be deep pink with edema and a small amount of sanguineous drainage. What action should the nurse take?

d. Document stoma assessment findings. The stoma appearance indicates good circulation to the stoma. There is no indication that surgical intervention is needed or that frequent stoma monitoring is required. Swelling of the stoma is normal for 2 to 3 weeks after surgery. An ice pack is not needed.

A patient who has chronic constipation asks the nurse about the use of psyllium (Metamucil). Which information will the nurse include in the response?

d. Large amounts of fluid should be taken to prevent impaction or bowel obstruction. A high fluid intake is needed when patients are using bulk-forming laxatives to avoid worsening constipation. Although bulk-forming laxatives are generally safe, the nurse should emphasize the possibility of constipation or obstipation if inadequate fluid intake occurs. Although increased gas formation is likely to occur with increased dietary fiber, the patient should gradually increase dietary fiber and eventually may not need the psyllium. Fat-soluble vitamin absorption is blocked by stool softeners and lubricants, not by bulk-forming laxatives

After several days of antibiotic therapy for pneumonia, an older hospitalized patient develops watery diarrhea. Which action should the nurse take first?

d. Place the patient on contact precautions. The patient's history and new onset diarrhea suggest a C. difficile infection, which requires implementation of contact precautions to prevent spread of the infection to other patients. The other actions are also appropriate but can be accomplished after contact precautions are implemented.

The nurse is providing preoperative teaching for a patient scheduled for an abdominal-perineal resection. Which information will the nurse include?

d. The site where the stoma will be located will be marked on the abdomen preoperatively. D A wound, ostomy, continence nurse (WOCN) should select the site where the ostomy will be positioned and mark the abdomen preoperatively. The site should be within the rectus muscle, on a flat surface, and in a place that the patient is able to see. A permanent colostomy is created with this surgery. The patient will be encouraged to walk the day after surgery. Oral antibiotics (rather than IV antibiotics) are given to reduce colonic and rectal bacteria.